Acute ischemic stroke with cervical internal carotid artery steno-occlusive lesion: multicenter analysis of endovascular approaches

Abstract

Background Occlusions of internal carotid artery (ICA), whether isolated or in tandem lesions (TL) have a poor response to treatment with intravenous thrombolysis. Previous studies ​​have demonstrated the superiority of mechanical thrombectomy in the treatment of acute ischemic stroke (AIS) following large vessel occlusion, compared to standard intravenous fibrinolysis. The aim of our study was to describe endovascular treatment (EVT) in AIS due to ICA occlusion, whether isolated or in TL. Methods we assessed the association between 90-day outcome and clinical, demographic, imaging and procedure data in 51 consecutive patients with acute isolated ICA or TL occlusion who underwent endovascular treatment (EVT). We evaluated baseline NIHSS and mRS, ASPECTS, type of occlusion, stent placement, use of stent retrievers and/or thromboaspiration, duration of the procedure, mTICI, procedural therapy and complications. Results A favorable 90-day outcome (mRS 0–2) was achieved in 34 patients (67%) and was significantly associated with the use of dual antiplatelet therapy after the procedure (p = 0.008), shorter procedure duration (p = 0.031), TICI 2b-3 (p < 0.001) and lack of post-procedural hemorrhagic transformation (p = 0.001). Four patients did not survive, resulting in a mortality rate of 8% Conclusions EVT in the treatment of AIS due to ICA occlusion is safe and effective; mortality rates are in agreement with the current literature. The use of the stent is safe and promotes good angiographic results, as well as therapy with a GpIIb / IIIa inhibitor immediately after stent release which is also associated with better 3-month outcome and good revascularization.

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

“…Regrettably, we could not obtain any specific information regarding reasons for non-referral/non-acceptance for EMR. Likely contributing factors include: (1) "symptomatic" carotid disease being historically considered a primarily surgical disease, to be addressed within 14 days from symptom onset [23]; (2) CSCs primary focus on intracranial LVO management [8,19,20]; (3) unfamiliarity with the treatment of carotid origin disease under flow reversal [7,21,45]; (4) shortage of stroke MT centers [50,51]; and (5) lack of established pathways for emergency AIS-CA stroke referrals that would involve centers with expertise in endovascular carotid revascularization [49]. Furthermore, clinical practice suggests that rejection of a particular patient type will impact further referrals of similar patients.…”

“…Carotid atherosclerotic disease is an important [1][2][3][4] yet underestimated [5] cause of ischemic stroke. Strokes of carotid bifurcation origin constitute at least 20% of ischemic strokes [1,6]; some of those present with a co-existing occlusion of the intracranial vessel(s) (tandem lesions) [7,8]. Acute ischemic stroke of extracranial carotid artery origin (AIS-CA) has an unfavorable clinical prognosis due to the large volume of affected brain tissue and the typically large thrombus load, with recanalization rates below 10% using systemic intravenous thrombolysis (IVT) [9][10][11].…”

Emergent carotid endarterectomy and mechanical thrombectomy in tandem occlusion

“…Cirillo et al found that endovascular ICA stenting used in management of tandem occlusions led to improved revascularization and had improved long-term morbidity and mortality when compared to non-stenting techniques. [1] is methodology of endovascular intervention, in addition to MT, has been widely accepted as more successful compared to thrombolysis alone. e thrombectomy in tandem lesions collaboration compiled several cases of tandem occlusions involving the anterior circulation to compare the speed and rates of reperfusion in headfirst versus neck-first endovascular approaches.…”