Efficacy and Safety of Endovascular Treatment in Acute Tandem Carotid Occlusions: Analysis of a Single-Center Cohort

Development of a Novel Statistical Model for Predicting Clinical Outcomes in Stroke Patients With Tandem Occlusions After Endovascular Therapy

BACKGROUND

Tandem occlusions are intracranial large vessel occlusions (LVOs) with a concomitant ipsilateral extracranial internal carotid artery occlusion and can cause more severe stroke symptoms.

AIM

To develop a simple, rigorously cross-validated novel tool to predict clinical outcomes following tandem occlusion in patients with acute LVO stroke, based on data that are easily available to clinicians. To have used machine learning approaches to utilize the available information from clinical and angiographic data to make predictive models able to distinguish between mortality versus survival and good (modified Rankin Scale (mRS) ≤ 2) versus unfavorable neurological outcomes (mRs ≥ 3) Materials and methods: Retrospective data from 87 consecutive patients with anterior circulation stroke and tandem occlusions who underwent mechanical thrombectomy and stenting between December 2009 and January 2020 were analyzed. Patients were stratified into three groups based on the location of their LVO, and these groups were compared using statistical tests. Predictive models were built and cross-validated 1000 times to estimate their predictive power, measured by accuracy and area under the receiver operating curve (AUROC).

RESULTS

For distinguishing good outcome (mRS ≤ 2) versus poor outcome (mRS ≥ 3), the model comprised age, initial National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early CT Score (ASPECTS), NIHSS at 24 hours, NIHSS at discharge and intracranial haemorrhage and yielded an accuracy of 83% and the AUROC of 0.91. For mortality prediction, the model comprised age, initial NIHSS, intravenous thrombolysis, NIHSS at 24 hours and NIHSS at discharge and yielded an accuracy of 91% and an AUROC of 0.94.

CONCLUSIONS

Models developed exhibit strong predictive performance and can distinguish between both the instances of survival versus mortality and good versus poor outcome with an aim to support clinicians in deciding on optimal management for these complex patients. The developed model will help identify those at risk of poorer outcomes and the prospective better selection of patients with acute ischaemic large vessel stroke secondary to tandem occlusions.

Bridging techniques compared with direct endovascular therapy for stroke due to tandem occlusion: A systematic review and meta-analysis

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.

Differences in risk factors and outcome after acute stroke in patients with tandem occlusion and those with isolated intracranial occlusion after endovascular treatment

OBJECTIVE

This study aimed to compare the clinical features, treatment, and clinical outcome of patients with tandem occlusion and isolated intracranial occlusion through endovascular treatment (EVT).

METHODS

Patients with acute cerebral infarction who received EVT in two stroke centers were retrospectively included. According to MRI or CTA results, the patients were divided into tandem occlusion group or isolated intracranial occlusion group. The baseline data, etiological classification, treatment, post-stroke complications, image features, and clinical outcome were compared. Multivariate logistic regression analysis was used to evaluate the related factors affecting the prognosis of patients with EVT.

RESULTS

Among 161 patients with acute cerebral infarction, there were 33 cases (20.5%) in the tandem occlusion group and 128 cases (79.5%) in the isolated intracranial occlusion group. Compared with isolated intracranial occlusion, the patients with tandem occlusion had higher rates of large artery atherosclerosis (P = 0.028), symptomatic intracerebral hemorrhage (sICH) (P = 0.023), bilateral infarction (P = 0.042), and longer time for endovascular procedure (P = 0.026). There was no significant statistical difference in 90-day mRS score between the two groups (P = 0.060). Multivariate logistic regression identified the following independent predictors of poor functional outcome: older age, high fasting blood glucose, infarction area > 1/3, and hemorrhagic transformation.

CONCLUSIONS

Compared with isolated intracranial occlusion, there was not a worse prognosis among patients with tandem occlusion who received EVT.

Safety and Efficacy of Tenecteplase and Alteplase in Patients With Tandem Lesion Stroke: A Post Hoc Analysis of the EXTEND-IA TNK Trials

BACKGROUND AND OBJECTIVES

The safety and efficacy of tenecteplase (TNK) in patients with tandem lesion (TL) stroke is unknown. We performed a comparative analysis of TNK and alteplase in patients with TLs.

METHODS

We first compared the treatment effect of TNK and alteplase in patients with TLs using individual patient data from the EXTEND-IA TNK trials. We evaluated intracranial reperfusion at initial angiographic assessment and 90-day modified Rankin scale (mRS) with ordinal logistic and Firth regression models. Because 2 key outcomes, mortality and symptomatic intracranial hemorrhage (sICH), were few in number among those who received alteplase in the EXTEND-IA TNK trials, we generated pooled estimates for these outcomes by supplementing trial data with estimates of incidence obtained through a meta-analysis of studies identified in a systematic review. We then calculated unadjusted risk differences to compare the pooled estimates for those receiving alteplase with the incidence observed in the trial among those receiving TNK.

RESULTS

Seventy-one of 483 patients (15%) in the EXTEND-IA TNK trials possessed a TL. In patients with TLs, intracranial reperfusion was observed in 11/56 (20%) of TNK-treated patients vs 1/15 (7%) alteplase-treated patients (adjusted odds ratio 2.19; 95% CI 0.28-17.29). No significant difference in 90-day mRS was observed (adjusted common odds ratio 1.48; 95% CI 0.44-5.00). A pooled study-level proportion of alteplase-associated mortality and sICH was 0.14 (95% CI 0.08-0.21) and 0.09 (95% CI 0.04-0.16), respectively. Compared with a mortality rate of 0.09 (95% CI 0.03-0.20) and an sICH rate of 0.07 (95% CI 0.02-0.17) in TNK-treated patients, no significant difference was observed.

DISCUSSION

Functional outcomes, mortality, and sICH did not significantly differ between patients with TLs treated with TNK and those treated with alteplase.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that TNK is associated with similar rates of intracranial reperfusion, functional outcome, mortality, and sICH compared with alteplase in patients with acute stroke due to TLs. However, the CIs do not rule out clinically important differences. TRIAL REGISTRATION INFORMATION: clinicaltrials.gov/ct2/show/NCT02388061; clinicaltrials.gov/ct2/show/NCT03340493.

Effectiveness of Guiding Catheter Retrieval Balloon Technique in the Treatment of Acute Anterior Circulation Tandem Occlusion: A Retrospective Study

BACKGROUND

Tandem occlusion accounts for 10%-20% of all large vessel occlusion strokes and often yields a poor recanalization rate. The endovascular treatment of tandem lesions is still controversial. This study uses an endovascular treatment strategy, "guided catheter recovery balloon (GRB)" for the treatment of acute anterior circulation tandem occlusion.

METHODS

A retrospective design was adopted. The population included patients with acute tandem occlusion who received emergency GRB endovascular treatment. And the choice of stenting was made based on intraoperative radiography imaging. Recanalization was evaluated by the thrombolysis in cerebral infarction score after the operation. Three-month modified Rankin Scale follow-up results were recorded, and modified Rankin Scale ≤2 was considered favorable recovery.

RESULTS

A total of 55 patients aged 66.9 ± 8.5 years were enrolled, 37 of whom received stenting. The mean overall recanalization time was 46 minutes. Fifty (90.9%) patients achieved successful recanalization with a thrombolysis in cerebral infarction score of 2b-3. At the 3-month follow-up, the number of patients with favorable functional recovery was 28 (50.9%). The presence of hypertension was correlated with a favorable recovery outcome: 82.1% of the favorable recovery population had hypertension, and 55.6% of the unfavorable outcome population had hypertension (P = 0.033). There was no statistically significant association between stent application and favorable recovery outcomes (P = 0.504).

CONCLUSIONS

GRB technique showed a high recanalization rate when applied to the treatment of acute anterior circulation tandem occlusion.

Risk factors of hemorrhagic transformation in acute ischaemic stroke: A systematic review and meta-analysis

Background

Hemorrhagic transformation (HT) following reperfusion therapies for acute ischaemic stroke often predicts a poor prognosis. This systematic review and meta-analysis aims to identify risk factors for HT, and how these vary with hyperacute treatment [intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT)].

Methods

Electronic databases PubMed and EMBASE were used to search relevant studies. Pooled odds ratio (OR) with 95% confidence interval (CI) were estimated.

Results

A total of 120 studies were included. Atrial fibrillation and NIHSS score were common predictors for any intracerebral hemorrhage (ICH) after reperfusion therapies (both IVT and EVT), while a hyperdense artery sign (OR = 2.605, 95% CI 1.212-5.599, I ² = 0.0%) and number of thrombectomy passes (OR = 1.151, 95% CI 1.041-1.272, I ² = 54.3%) were predictors of any ICH after IVT and EVT, respectively. Common predictors for symptomatic ICH (sICH) after reperfusion therapies were age and serum glucose level. Atrial fibrillation (OR = 3.867, 95% CI 1.970-7.591, I ² = 29.1%), NIHSS score (OR = 1.082, 95% CI 1.060-1.105, I ² = 54.5%) and onset-to-treatment time (OR = 1.003, 95% CI 1.001-1.005, I ² = 0.0%) were predictors of sICH after IVT. Alberta Stroke Program Early CT score (ASPECTS) (OR = 0.686, 95% CI 0.565-0.833, I ² =77.6%) and number of thrombectomy passes (OR = 1.374, 95% CI 1.012-1.866, I ² = 86.4%) were predictors of sICH after EVT.

Conclusion

Several predictors of ICH were identified, which varied by treatment type. Studies based on larger and multi-center data sets should be prioritized to confirm the results.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=268927, identifier: CRD42021268927.

The Relationship Between Neuron-Specific Enolase and Clinical Outcomes in Patients Undergoing Mechanical Thrombectomy

Purpose

Neuron-specific enolase (NSE) is considered a biomarker for the severity of nervous system diseases. We sought to explore whether serum NSE concentration in ischemic stroke patients undergoing mechanical thrombectomy (MT) is related to 3-month functional outcome and symptomatic intracranial hemorrhage (sICH).

Patients and Methods

We retrospectively collected the data of acute ischemic stroke patients with anterior circulation infarction receiving MT within 6 h in our stroke center. Favorable outcome and poor outcome at 3 months were defined as modified Rankin Scale (mRS) score 0-2 and 3-6, respectively. sICH was defined according to the Heidelberg bleeding classification. We used multivariate logistic regression model and receiver operating characteristic curves to investigate the correlation between NSE and clinical outcomes.

Results

Among the 426 patients enrolled, 40 (9.4%) patients developed sICH. Three-month favorable outcome in 160 (37.6%) and poor outcome in 266 (62.4%) patients were observed. Serum NSE levels was significantly correlated with 3-month mRS score (R = 0.473, P < 0.001). A cutoff value of 15.29 and 23.12 ng/mL for serum NSE was detected in discriminating 3-month poor outcome (area under the curve, 0.724) and sICH (area under the curve, 0.716), respectively. Multivariate analysis showed that high serum NSE levels were independently associated with 3-month poor outcome (odds ratio [OR] 5.049, 95% confidence interval [CI] 2.933-8.689, P<0.001) and sICH (OR 5.111, 95% CI 2.210-11.820, P < 0.001).

Conclusion

Our study demonstrated that high serum NSE levels after receiving MT were independently associated with 3-month poor outcome and sICH in acute ischemic stroke patients. Serum NSE levels could be a good predictor of clinical outcomes for patients receiving MT.

A systematic review and meta-analysis of carotid artery stenting for the treatment of cervical carotid artery dissection

OBJECTIVE

To assess the efficacy and safety of carotid artery stenting for the treatment of extracranial carotid artery dissection (CAD).

DATA SOURCES

Systematic review using Medline, Scopus, EMBASE and Cochrane Library.

REVIEW METHODS

A systematic search was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. Data from the eligible studies were extracted and meta-analyzed. Primary endpoints included postoperative mortality, cerebrovascular events (CE) and modified Rankin Score for neurologic disability (mRS) at 90 days. We performed subgroup analyses between stenting of spontaneous and traumatic CAD, primary stenting versus stenting after failed medical therapy (FMT) and stenting of CAD in the presence of tandem occlusions versus stenting of isolated extracranial CAD.

RESULTS

Twenty-four studies with 1,224 patients were included. Pooled post-operative mortality, CE and mRS 0-2 rates were 1.71% (95%CI:0.83-2.80), 6.45% (95%CI:2.80-11.10) and 76.13% (95%CI:64.15-86.50), respectively. The pooled stroke rate was 2.16% (95%CI:0.0-6.64). Spontaneous versus traumatic CAD mortality rates were 3.20% (95%CI:1.80-4.88) and 0.00% (95%CI:0.00-1.59) while CE rates were 14.26% (95%CI:6.28-24.36) and 1.64% (95%CI:0.0-6.08). Primary stenting and stenting after FMT mortality rates were 0.63% (95%CI:0.0-5.63) and 0.0% (95%CI:0.0-2.24), while CE rates were 5.02% (95%CI:0.38-12.63) and 3.33% (95%CI:0.12-9.03). Mortality rates for tandem occlusions and isolated extracranial CAD were 5.62% (95%CI:1.76-10.83) and 0.23% (95%CI:0.0-1.88) respectively, while CE rates were 15.28% (95%CI:6.23-26.64) and 1.88% (95%CI:0.23-4.51). The methodological index for non-randomized studies (MINORS) score was 8.66 (low).

CONCLUSION

Both primary stenting and stenting of spontaneous CAD yielded unfavorable results regarding stent thrombosis and stroke rates. Conversely, stenting following FMT displayed acceptable mortality and complication rates corroborating the use of stenting in the setting of CAD as a second line treatment. Due to the low quality of the included studies, definite conclusions cannot be drawn necessitating further research.

Passing Extracranial Artery Occlusion by Intermediate Catheter With Expanding Microballoon (PEACE): A Novel Endovascular Therapy in Acute Tandem Occlusion Stroke

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.

Management and outcome of patients with acute ischemic stroke and tandem carotid occlusion in the ESCAPE-NA1 trial

BACKGROUND

The optimal treatment and prognosis for stroke patients with tandem cervical carotid occlusion are unclear. We analyzed outcomes and treatment strategies of tandem occlusion patients in the ESCAPE-NA1 trial.

METHODS

ESCAPE-NA1 was a multicenter international randomized trial of nerinetide versus placebo in 1105 patients with acute ischemic stroke who underwent endovascular treatment. We defined tandem occlusions as complete occlusion of the cervical internal carotid artery (ICA) on catheter angiography, in addition to a proximal ipsilateral intracranial large vessel occlusion. Baseline characteristics and outcome parameters were compared between patients with tandem occlusions versus those without, and between patients with tandem occlusion who underwent ICA stenting versus those who did not. The influence of tandem occlusions on functional outcome was analyzed using multivariable regression modeling.

RESULTS

Among 115/1105 patients (10.4%) with tandem occlusions, 62 (53.9%) received stenting for the cervical ICA occlusion. Of these, 46 (74.2%) were stented after and 16 (25.8%) before the intracranial thrombectomy. A modified Rankin Score (mRS) of 0-2 at 90 days was achieved in 82/115 patients (71.3%) with tandem occlusions compared with 579/981 (59.5%) patients without tandem occlusions. Tandem occlusion did not impact functional outcome in the adjusted analysis (OR 1.5, 95% CI 0.95 to 2.4). Among the subgroup of patients with tandem occlusion, cervical carotid stenting was not associated with different outcomes compared with no stenting (mRS 0-2: 75.8% vs 66.0%, adjusted OR 2.0, 95% CI 0.8 to 5.1).

CONCLUSIONS

Tandem cervical carotid occlusion in patients with acute large vessel stroke did not lower the odds of good functional outcome in our study. Functional outcomes were similar irrespective of the management of the cervical ICA occlusion (stenting vs not stenting).

Hypersensitive C-reactive protein-albumin ratio predicts symptomatic intracranial hemorrhage after endovascular therapy in acute ischemic stroke patients

Background

Approximately 10% of patients would develop symptomatic intracranial hemorrhage (sICH) after endovascular therapy. The aim of our study was to explore the ability of hypersensitive C-reactive protein-albumin ratio (HAR) in predicting sICH after endovascular therapy.

Methods

From April 2016 to December 2018, 334 consecutive patients with anterior circulation infarction undergoing endovascular therapy were enrolled in our study. sICH was defined using Heidelberg bleeding classification after endovascular therapy. Multiple regression analysis was used to investigate the potential risk factors of sICH after endovascular therapy. We used receiver operating characteristic curve analysis and nomogram analysis to assess the overall discriminative ability of the HAR in predicting sICH after endovascular therapy.

Results

Among these 334 patients enrolled, 37 (11.1%) patients with anterior circulation infarction were identified with sICH after endovascular therapy. Univariate logistic regression analysis demonstrated that patients with higher levels of HAR may be inclined to develop sICH (odds ratio, 10.994; 95% confidence interval, 4.567–26.463; P = 0.001). This association remained significant even after adjustment for potential confounders. Also, a cutoff value of 0.526× 10^− 3 for HAR was detected in predicting sICH (area under curve, 0.763). Furthermore, nomogram analysis also suggested that HAR was an indicator of sICH (c-index was 0.890, P< 0.001).

Conclusions

This study showed that high levels of HAR could predict sICH after endovascular therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02066-2.