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Milazzo N, Da Ros V, Diomedi M, Menozzi R, Pezzini A, Ruggiero M, Simonetti L, Zini A, Romano DG, Napoletano R, Vallone S, Bigliardi G, Plebani M, Cappellari M, Cristaudo C, Mangiafico S, Toni D, Consoli A. Current trends in antiplatelet strategies for emergent carotid stenting in acute tandem occlusions: a web-based, nationwide survey in the Italian neurovascular community. Neurol Sci 2024:10.1007/s10072-024-07722-2. [PMID: 39158771 DOI: 10.1007/s10072-024-07722-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/29/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Although a benefit from mechanical thrombectomy has been proven, the best treatment strategy for tandem occlusions (TOs) remains unclear. We conducted a survey that aimed to investigate the trends of pharmacological strategy in the setting of emergent carotid stenting for TOs in the Italian neuro-endovascular community. METHODS We administered a 13-multiple choice-questions survey to the Chiefs of the centers participating to the Italian Registry of Endovascular Thrombectomy in Acute Stroke (IRETAS), focused on the technical aspects and on the management of the antiplatelet therapy for emergent carotid tenting in TOs. An internal coherence control was performed by the coordinating investigator. RESULTS We obtained responses from 56/66 centers (84.8%). The main results of the survey showed that most of the center treat TOs using a retrograde approach, deploying a closed-cell stent. A single antiplatelet therapy is preferred at the moment of the deployment of the stent. CONCLUSIONS This survey showed that the current practice regarding the acute management of TOs, in particular the antiplatelet therapy, remains heterogeneous in the Italian neurovascular community. Specific evidences are urgently needed in order to achieve a consensus on the acute management of TOs.
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Affiliation(s)
- Nicola Milazzo
- Diagnostic and Interventional Neuroradiology, Foch Hopital, Suresnes, France.
- UFR Simon Veil Santé, University of Versailles Saint-Quentin-en-Yvelines (UVSQ), Montigny-Le-Bretonneux, France.
- Maurizio Bufalini Hospital, Cesena, Italy.
| | - Valerio Da Ros
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Roberto Menozzi
- Diagnostic Department, Neuroradiology Unit, Parma University Hospital, Parma, Italy
| | - Alessandro Pezzini
- Stroke Care Program Department of Emergency, Parma University Hospital, Parma, Italy
| | | | - Luigi Simonetti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Daniele Giuseppe Romano
- Department of Interventional Radiology and Neuroradiology, University Hospital of Salerno, Salerno, Italy
| | - Rosa Napoletano
- Stroke Unit, Department of Medical Sciences, University Hospital of Salerno, Salerno, Italy
| | - Stefano Vallone
- Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena, NeuroradiologyModena, Italy
| | - Guido Bigliardi
- Neurology Clinic - Stroke Unit, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Mauro Plebani
- Department of Neuroradiology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Manuel Cappellari
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Salvatore Mangiafico
- Interventional Neuroradiology Consultant at IRCCS Neuromed, Pozzilli (IS), and Adjunct Professor of Interventional Neuroradiology at Tor Vergata University, Sapienza University and S. Andrea Hospital, Rome, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hopital, Suresnes, France
- UFR Simon Veil Santé, University of Versailles Saint-Quentin-en-Yvelines (UVSQ), Montigny-Le-Bretonneux, France
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2
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Baig AA, Waqas M, Turner RC, Kuo CC, Donnelly BM, Lai PMR, Raygor KP, Bouslama M, Lim J, Neumaier Bs J, Cappuzzo JM, Davies JM, Snyder KV, Siddiqui AH, Levy EI. A propensity score-matched comparative study of balloon guide catheters versus conventional guide catheters for concurrent mechanical thrombectomy with carotid stenting in tandem strokes: comparison of first pass effect, symptomatic intracranial hemorrhage, and 90-day functional outcomes. J Neurointerv Surg 2024; 16:124-130. [PMID: 37076277 DOI: 10.1136/jnis-2023-020114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/22/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Extensive clot burden in tandem strokes accounts for poor mechanical thrombectomy (MT) outcomes. Several studies have shown the benefit of balloon guide catheters (BGCs) in MT and carotid artery stenting. OBJECTIVE In view of this potential benefit, to investigate the safety and effectiveness of proximal flow arrest using a BGC during concurrent MT and carotid revascularization for tandem stroke treatment in a comparative, propensity score-matched (PSM) study. METHODS Patients with a tandem stroke identified from our endovascular database were dichotomized into groups treated with BGCs versus conventional guide catheters. One-to-one PSM adjustment for baseline demographics and treatment selection bias using nearest-neighbor matching was performed. Patient demographics, presentation characteristics, and procedural details were recorded. Outcomes assessed were final modified Thrombolysis in Cerebral Infarction (mTICI) grade, periprocedural symptomatic intracranial hemorrhage (sICH) rate, in-hospital mortality, and 90-day modified Rankin Scale (mRS) score. Mann-Whitney U test and multivariate logistic regression were performed to compare procedural parameters and clinical outcomes. RESULTS Concurrent carotid revascularization (stenting with/without angioplasty) and MT was performed in 125 cases (BGC: 85; no BGC: 40). After PSM (40 patients/group), the BGC group had a significantly shorter procedure duration (77.9 vs 61.5 min; OR=0.996; P=0.006), lower discharge National Institutes of Health Stroke Scale score (8.0 vs 11.0; OR=0.987; P=0.042), and higher odds of 90-day mRS 0-2 score (52.3% vs 27.5%; OR=0.34; P=0.040). On multivariate regression, the BGC group had a significantly higher first pass effect rate (mTICI 2b or 3)(OR=1.115, 95% CI 1.015 to 1.432; P=0.013) and lower periprocedural sICH rate (OR=0.615, 95% CI 0.406 to 0.932; P=0.025). No difference in in-hospital mortality was observed (OR=1.591, 95% CI 0.976 to 2.593; P=0.067). CONCLUSION BGCs used for concurrent MT-carotid revascularization with flow arrest were safe and resulted in superior clinical and angiographic outcomes in patients with a tandem stroke.
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Affiliation(s)
- Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ryan C Turner
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Brianna M Donnelly
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kunal P Raygor
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Mehdi Bouslama
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jenna Neumaier Bs
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Department Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Department Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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3
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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4
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Siddiq F, Bhagavan S, Ishfaq MF, Jaura A, Bhatti IA, Gomez CR, Qureshi AI. Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke. Oper Neurosurg (Hagerstown) 2023; 25:190-198. [PMID: 37133290 DOI: 10.1227/ons.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/08/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Acute ischemic stroke from tandem occlusion of internal carotid artery (ICA) poses a technical challenge to neurointerventionalists. OBJECTIVE To present a novel balloon-assisted catheterization of occluded carotid artery (BOCA) technique used for rapid and effective catheterization of occluded/critically stenosed ICA in tandem occlusion. METHODS A retrospective review of 10 patients with tandem carotid occlusion, treated with BOCA technique for revascularization between July 2020 and June 2021, was performed. Clinical, radiographic, and procedural data; details of BOCA technique; complications; and outcomes were reviewed. RESULTS Of the 10 patients, 8 (80%) had complete occlusion of the cervical ICA and the remaining 2 had high-grade stenosis with poor intracranial flow. The mean age was 63.2 years. The mean presenting NIH Stroke Scale was 13.4. The BOCA technique resulted in recanalization of ICA in all patients and allowed mechanical thrombectomy of middle cerebral artery. Thrombolysis in cerebral infarction grade 2b/3 was achieved in all 10 patients. The mean groin-to-reperfusion time was 41.4 minutes. The mean internal carotid artery stenosis was 99.7% preoperatively and 41.1% postoperatively. Only one patient needed stent at the end of the procedure because of dissection. CONCLUSION The BOCA technique can be used in distal first approach for acute stroke from tandem ICA occlusion. This technique allows direct guide catheterization of occluded ICA by tracking over a partially inflated balloon.
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Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Sachin Bhagavan
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - M Fawad Ishfaq
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Attiya Jaura
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | | | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
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5
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Min X, Du J, Bai X, Wei T, Dmytriw AA, Patel AB, Zhang X, Xu X, Feng Y, Wang T, Wang X, Yang K, Hu W, Yi T, Chen W, Jiao L. Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2022; 12:757665. [PMID: 35095720 PMCID: PMC8790816 DOI: 10.3389/fneur.2021.757665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection. Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b-3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0-2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle-Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I 2 statistic. Subgroup and sensitivity analyses were also performed. Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40-0.99, p = 0.04]. 90-day favorable outcome (mRS 0-2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58-0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups. Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results. Systematic Review Registration: "PROSPERO" database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.
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Affiliation(s)
- Xiaoli Min
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital, Kunming Medical University, Kunming, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianhua Du
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wei
- Library, Kunming Medical University, Kunming, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weiwu Hu
- Department of Neurology, The First Traditional Chinese Medicine Hospital of Chengde, Chengde, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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6
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Cheng Z, Rajah GB, Gao J, Geng X, Ding Y. Passing Extracranial Artery Occlusion by Intermediate Catheter With Expanding Microballoon (PEACE): A Novel Endovascular Therapy in Acute Tandem Occlusion Stroke. J Endovasc Ther 2021; 29:790-797. [PMID: 34894849 DOI: 10.1177/15266028211064818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Endovascular treatment of atherosclerotic tandem occlusions in acute ischemic stroke (AIS) is a matter of debate. This article reports a single-center experience using an intermediate catheter with microballoon for treatment of tandem occlusions. METHODS A total of 151 AIS patients with large vessel occlusion received endovascular therapy and a consecutive series of patients (n = 26) who suffered from tandem cervical intracranial occlusions were treated using the Passing Extracranial Artery Occlusion by Intermediate Catheter with Expanding Microballoon (PEACE) technique. Intracranial recanalization was achieved by aspiration or stent retriever and then emergency stenting was performed for extracranial internal carotid artery (ICA) lesion. Demographic, clinical characteristics, procedural details of endovascular therapy, and prognosis outcome were assessed. The outcomes of tandem occlusion group were compared with isolated intracranial occlusion group (n = 122) and previous studies. RESULTS As compared to isolated intracranial occlusion groups, only a few patients suffered from atrial fibrillation (7.7% vs 38.5%, p<0.01) in tandem occlusions group. A larger proportion of patients (61.5% vs 29.5%) had tandem occlusions in which extracranial ICA occlusion was combined with intracranial terminus occlusion in ICA (p<0.01). 46.2% of tandem occlusions patients achieved intracranial recanalization by aspiration alone versus 15.6% in patients with isolated intracranial occlusion (p<0.01). In tandem occlusion patients treated with PEACE, 92.3% achieved successful reperfusion (thrombolysis in cerebral infarct [TICI] ≥2b). The median time from puncture to recanalization was 51 minutes (interquartile range [IQR], 41-66). 67.6% favorable functional prognosis (modified Rankin score [mRS], 0-2) was seen, with 11.5% mortality and 3.8% of symptomatic intracerebral hemorrhage (sICH) at 90 days. These outcomes are all consistent or better than previously reported studies performed for tandem occlusion. CONCLUSIONS Endovascular therapy using the PEACE technique with intermediate catheter and lined expanding microballoon is safe, efficient, and fast in the treatment of atherosclerotic tandem occlusion patients.
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Affiliation(s)
- Zhe Cheng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Gary B Rajah
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.,Department of Neurosurgery, Munson Healthcare, Traverse City, MI, USA
| | - Jie Gao
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Yuchuan Ding
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, School of Medicine, Wayne State University, Detroit, MI, USA
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7
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Yeo LLL, Jing M, Bhogal P, Tu T, Gopinathan A, Yang C, Tan BYQ, Arnberg F, Sia CH, Holmin S, Andersson T. Evidence-Based Updates to Thrombectomy: Targets, New Techniques, and Devices. Front Neurol 2021; 12:712527. [PMID: 34566856 PMCID: PMC8459011 DOI: 10.3389/fneur.2021.712527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/30/2021] [Indexed: 01/23/2023] Open
Abstract
Endovascular thrombectomy (EVT) has been validated in several randomized controlled trials in recent years for its efficacy in the treatment of acute ischemic strokes (AIS) and is now the standard of care according to international guidelines. However, in about 20% of EVT procedures, recanalization is not achieved, and over 50% of patients who undergo EVT still do not have good functional outcome. In this article, we provide an extensive review of the latest evidence and developments in the field of EVT, with particular focus on the factors that improve patient outcomes. These factors include new and adjunctive techniques such as combination of direct aspiration and stent retriever, intra-arterial urokinase or 2b/3a inhibitors, rescue stenting, as well as novel devices including balloon guide catheters and the newer generations of aspiration catheters and stent retrievers. We also examined the latest notion of using first-pass effect (FPE) as the target to achieve during EVT, which has been associated with an improved functional outcome. While the field of EVT has been rapidly evolving, further research is required in specific AIS patient populations such as those with large ischemic core, late presentation beyond 24 h, posterior circulation strokes, and with distal medium vessel occlusion or tandem lesions to better assess its efficacy and safety.
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Affiliation(s)
- Leonard L L Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Mingxue Jing
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Pervinder Bhogal
- Department of Neuroradiology, St. Bartholomew's and the Royal London Hospital, London, United Kingdom
| | - Tianming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Anil Gopinathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Benjamin Y Q Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
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8
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Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Patterson M, Below K, Martins SO, Mansour OY, Mont'Alverne F, Nguyen TN, Lemme L, Siddiqui AH, Fraser JF, Jadhav AP, Zaidat OO, Ortega-Gutierrez S. Proximal Internal Carotid artery Acute Stroke Secondary to tandem Occlusions (PICASSO) international survey. J Neurointerv Surg 2020; 13:1106-1110. [PMID: 33323501 DOI: 10.1136/neurintsurg-2020-017025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND While mechanical thrombectomy (MT) is the standard of care for large vessel occlusion strokes, the optimal management of tandem occlusions (TO) remains uncertain. We aimed to determine the current practice patterns among stroke physicians involved in the treatment of TO during MT. METHODS We distributed an online survey to neurovascular practitioners (stroke neurologists, neurointerventionalists, neurosurgeons, and radiologists), members of professional societies. After 2 months the site was closed and data were extracted and analyzed. We divided respondents into acute stenting and delayed treatment groups and responses were compared between the two groups. RESULTS We received 220 responses from North America (48%), Latin America (28%), Asia (15%), Europe (5%), and Africa (4%). Preferred timing for cervical revascularization varied among respondents; 51% preferred treatment in a subsequent procedure during the same hospitalization whereas 39% preferred to treat during MT. Angioplasty and stenting (41%) was the preferred technique, followed by balloon angioplasty and local aspiration (38%). The risk of intracerebral hemorrhage was the most compelling reason for not stenting acutely (68%). There were no significant differences among practice characteristics and timing groups. Most practitioners (70%) agreed that there is equipoise regarding the optimal endovascular treatment of cervical lesions in TO; hence, 77% would participate in a randomized controlled trial. CONCLUSIONS The PICASSO survey demonstrates multiple areas of uncertainty regarding the medical and endovascular management of TOs. Experts acknowledged the need for further evidence and their willingness to participate in a randomized controlled trial to evaluate the best treatment for the cervical TO lesion.
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Affiliation(s)
- Cynthia B Zevallos
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Alan Mendez-Ruiz
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mary Patterson
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Kristine Below
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Sheila O Martins
- Neurology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ossama Y Mansour
- Neurology, Stroke and NeuroInterventional Unit, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | | | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Luis Lemme
- Interventional Neuroradiology, Centro Endovascular Neurologico Buenos Aires, Buenos Aires, Argentina
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Justin F Fraser
- Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | | | - Osama O Zaidat
- Neuroscience, St Vincent Mercy Hospital, Toledo, Indiana, USA
| | - Santiago Ortega-Gutierrez
- Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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9
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Watanabe S, Oda J, Nakahara I, Matsumoto S, Suyama Y, Hasebe A, Suzuki T, Tanabe J, Suyama K, Hirose Y. Experimental Analysis of Intra-luminal Pressure by Contrast Injection during Mechanical Thrombectomy: Simulation of Rupture Risk of Hidden Cerebral Aneurysm in Tandem Occlusion with Blind Alley. Neurol Med Chir (Tokyo) 2020; 60:286-292. [PMID: 32448828 PMCID: PMC7301125 DOI: 10.2176/nmc.oa.2019-0265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Mechanical thrombectomy using a retrograde approach is performed for tandem occlusion of the internal carotid artery (ICA). In our patient, a guiding catheter was easily passed by the stenosed lesion despite severe stenosis at the ICA origin. Therefore, we aimed to recanalize the occlusion of the terminal ICA without angioplasty for the stenosed lesion. When contrast was injected, a massive extravasation of contrast from the C2 portion of the ICA was observed. It was speculated that the bleeding was caused by rupture of an aneurysm at that site due to increased intra-arterial pressure caused by the contrast injection to a blind alley, which was created by a wedged guiding catheter at severe stenosis at the ICA origin and the occlusion of the terminal ICA. Our simulation experiment using a silicon vascular model in this situation demonstrated that the elevation of intra-arterial pressure in such blind alley reached over 50, 100, and 200 mmHg by injection of contrast from a microcatheter, a 4-Fr inner catheter, and a 9-Fr balloon-guiding catheter, respectively. When a retrograde approach is planned for tandem occlusion of the ICA, even when the proximal lesion is easily passed, prior angioplasty for the proximal lesion should be considered to avoid wedging by catheter.
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Affiliation(s)
- Sadayoshi Watanabe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine
| | - Jumpei Oda
- Department of Comprehensive Strokology, Fujita Health University School of Medicine
| | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University School of Medicine
| | - Shoji Matsumoto
- Department of Comprehensive Strokology, Fujita Health University School of Medicine
| | - Yoshio Suyama
- Department of Comprehensive Strokology, Fujita Health University School of Medicine
| | - Akiko Hasebe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine
| | - Takeya Suzuki
- Department of Comprehensive Strokology, Fujita Health University School of Medicine
| | - Jun Tanabe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine
| | - Kenichiro Suyama
- Department of Comprehensive Strokology, Fujita Health University School of Medicine
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University School of Medicine
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10
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Wang D, Zhang L, Hu X, Zhu J, Tang X, Ding D, Wang H, Kong Y, Cai X, Lin L, Fang Q. Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion. Front Neurol 2020; 11:340. [PMID: 32431662 PMCID: PMC7214684 DOI: 10.3389/fneur.2020.00340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023] Open
Abstract
At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stroke patients (National Institutes of Health Stroke Scale ≤5) with and without recombinant tissue plasminogen activator (rt-PA) therapy. The TOAST (Trial of Org 10172 in acute stroke treatment) criteria was used to determine stroke subtypes. Patients suffering from large-artery atherosclerosis (LAA) were subdivided based upon whether or not they exhibited tandem steno-occlusion, as defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery lesion (complete occlusion or severe stenosis ≥ 90%). For this study, favorable outcomes at 90 days of onset (modified Rankin Scale Score [mRS] of 0–1) were the primary measured outcome. Three hundred thirty-nine patients were included in the study. For patients with non-LAA, there were not statistically significant improvements in favorable outcomes for rt-PA treatment (p = 0.889, 0.929, 0.708; respectively). For patients with LAA, compared with non-treated group, rt-PA-treated patients had a significant in the rate of favorable outcomes at 90 days (82.8 vs. 64.9%; OR 2.59; 95%CI, 1.13–5.92; P = 0.024). Among LAA patients exhibiting tandem lesions, favorable outcomes were observed in 66.7% of rt-PA-treated patients, with no significant differences to those observed in untreated patients (OR 1.00; 95%CI, 0.23–4.28; p = 1.000). Among LAA patients without tandem lesions, compared with non-treated group, we found that rt-PA treatment was associated with a significant beneficial impact on favorable outcomes after 90 days (64.4 vs. 88.4%; OR 4.20; 95%CI, 1.43–12.30; p = 0.009). Our findings suggest that intravenous rt-PA is only beneficial in mild stroke patients with LAA-type strokes that do not exhibit tandem steno-occlusion.
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Affiliation(s)
- Dapeng Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Lulu Zhang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiaowei Hu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Juehua Zhu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiang Tang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Dongxue Ding
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Hui Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Yan Kong
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiuying Cai
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Longting Lin
- Hunter Medical Research Institute, University of Newcastle, New Lambton, NSW, Australia
| | - Qi Fang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
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11
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Gemmete JJ, Wilseck Z, Pandey AS, Chaudhary N. Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke. Semin Intervent Radiol 2020; 37:207-213. [PMID: 32419734 DOI: 10.1055/s-0040-1709207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There is no consensus for the treatment of a tandem occlusion (TO) in a patient presenting with an acute ischemic stroke. In this review article, we will focus on the controversial treatment strategies for TOs. First, we will discuss treatment options including retrograde, antegrade, and delayed approaches. Second, the role of carotid stent placement versus balloon angioplasty for the extracranial occlusion will be presented. Third, anticoagulation and antiplatelet regimens for the treatment TOs published in the literature will be reviewed. Finally, we will discuss whether there is a role for coil occlusion of the cervical carotid artery or whether staged carotid revascularization days after mechanical thrombectomy of the intracranial occlusion maybe appropriate. The optimal treatment strategy of TO has not been established and further larger trials need to be performed to answer the question.
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Affiliation(s)
- Joseph J Gemmete
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan.,Department of Neurosurgery, Michigan Medicine, Ann Arbor, Michigan
| | - Zachary Wilseck
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan
| | - Aditya S Pandey
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan.,Department of Neurosurgery, Michigan Medicine, Ann Arbor, Michigan
| | - Neeraj Chaudhary
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan.,Department of Neurosurgery, Michigan Medicine, Ann Arbor, Michigan
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12
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Bagley JH, Priest R. Carotid Revascularization: Current Practice and Future Directions. Semin Intervent Radiol 2020; 37:132-139. [PMID: 32419725 DOI: 10.1055/s-0040-1709154] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Carotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.
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Affiliation(s)
- Jacob H Bagley
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - Ryan Priest
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon
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13
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Vu-Dang L, Nguyen QA, Nguyen-Thi-Thu T, Tran AT, Le-Chi C, Le-Hoang K, Nguyen-Tat T, Nguyen-Huu A, Pham-Minh T, Chu-Dinh T, Chu DT. Endovascular Treatment for Acute Tandem Occlusion Stroke: Results from Case Series of 17 Patients. Ann Indian Acad Neurol 2020; 23:78-83. [PMID: 32055126 PMCID: PMC7001425 DOI: 10.4103/aian.aian_464_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background and Purpose: Tandem occlusive lesion, a major challenge for thrombectomy in acute anterior circulation strokes, is poorly represented in randomized trials. This study demonstrates the findings of thrombectomy in tandem occlusion and comparative analysis of two treatment groups (extracranial versus intracranial first subgroup). Patients and Methods: We enrolled and divided 17 patients with acute tandem ischemic stroke who received endovascular treatment into two groups. Group 1 with completed (100%) internal carotid artery (ICA) occlusion was treated by an extracranial stent, whereas Group 2 with severe (70%–99%) ICA occlusion was prioritized with intracranial thrombectomy. Data of clinical parameters, imaging and angiographic results, periprocedural complications, and results after 3 months were collected and analyzed. Results: The mean age of patients was 70.2 ± 8.8 years, and males accounted for 94.1%. The National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score (ASPECTS) baseline were 16.6 ± 4.2 and 7.6 ± 1.1, respectively, with occlusive side was 52.9% on the right. Group 1 including ten cases (58.8%) was treated extracranial lesion with carotid stent before intracranial thrombectomy, and Group 2 with seven cases (41.2%) was prioritized intracranial thrombectomy. In total 17 procedures, there were ten stent retrievers (58.8%), four aspirations (23.5%), and three Solumbra (17.7%). No re-occlusion of carotid stent postoperation was recorded. The good revascularization (thrombolysis in cerebral infarction 2b-3) was archived in 82.4% of patients, while symptomatic hemorrhage was seen in 2 cases (11.8%). Three months after treatment, patients with favorable clinical outcome (Modified Rankin Scale ≤2) accounted for 47.1%. Conclusion: Our study determined a promising outcome with reasonable good recanalization and clinical recovery for endovascular intervention in tandem ischemic. In the subgroup of treatment, “extracranial stent first” had more complex disease with completed ICA occlusion which required longer procedure time may lead to worse outcome.
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Affiliation(s)
- Luu Vu-Dang
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam.,Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Quang-Anh Nguyen
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam.,Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | | | - Anh-Tuan Tran
- Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Cong Le-Chi
- Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Kien Le-Hoang
- Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | | | - An Nguyen-Huu
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam
| | - Thong Pham-Minh
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam.,Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Thien Chu-Dinh
- Institute for Research and Development, Duy Tan University, Danang, Vietnam
| | - Dinh-Toi Chu
- Faculty of Biology, Hanoi National University of Education, Hanoi, Vietnam
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