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

Abstract

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.

Order of Treatment Matters in Ischemic Stroke: Mechanical Thrombectomy First, Then Carotid Artery Stenting for Tandem Lesions of the Anterior Circulation

“…Based on our current analysis, we suggest that patients suffering from acute TO should not be deprived of acute CAS. Reasons for this might be that (i) the vulnerable carotid lesion is stabilized, which prevents further cerebral thromboembolism within the post-interventional period, and (ii) the occurrence of sICH in acute TO seems justifiable with a rate between 5 and 11%, as demonstrated in large studies [7,8,23,[35][36][37]. Furthermore, the recent sub-analysis of the ESCAPE trial demonstrated that TO patients undergoing acute carotid intervention tended to have a better clinical outcome compared to staged treatment or medical therapy alone (65 vs. 54%) [5].…”

“…The study was conducted in accordance with the Declaration of Helsinki. Clinical data of some of the patients have been published in previous studies in a different context [7,8].…”

Carotid Artery Stenosis Contralateral to Intracranial Large Vessel Occlusion: An Independent Predictor of Unfavorable Clinical Outcome After Mechanical Thrombectomy

“…All patients treated due to isolated occlusion of anterior cerebral artery and with an unknown onset of symptoms were excluded. Patients treated with MT and acute carotid artery stenting due to tandem occlusions were excluded as this cohort was analyzed in a prior study ( 10 ). According to neurological guidelines, patients received IVT whenever possible.…”

“…In case of a horizontal or tortuous course of the vessel or a very short stenosis, maximum intensity projections and reconstructions were consulted ( 19 ). A luminal stenosis of >50% was defined as a relevant CCAS ( 10 ). The amount of contrast agent was 1.2–1.5 mL/kg body mass and minimum flow rate was 4.5 mL/s.…”

“…In a previous study, we observed that for patients undergoing MT and carotid artery stenting due to acute anterior tandem occlusion, the presence of a contralateral carotid artery stenosis >50% is an independent predictor of unfavorable clinical outcome, which presumably was a consequence of poorer collateral flow to the affected tissue ( 10 ). In this study, we analyzed the impact of a concomitant extracranial carotid artery stenosis (CCAS) contralateral to an intracranial LVO and hypothesized that the presence of a contralateral CCAS has a negative impact on the clinical outcome at 90 days.…”