Endovascular Treatment of Acute Ischemic Stroke Due to Tandem Occlusions: Large Multicenter Series and Systematic Review

Grigoryan, Mikayel; Haussen, Diogo C; Hassan, Ameer E.; Lima, Andrey; Grossberg, Jonathan A; Rebello, Letícia C; Tekle, Wondwossen G; Frankel, Michael; Nogueira, Raul G

doi:10.1159/000444069

Cited by 72 publications

(66 citation statements)

References 31 publications

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“…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].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2018

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Background: One endovascular treatment option of acute ischemic stroke due to tandem occlusion (TO) comprises intracranial thrombectomy and acute extracranial carotid artery stenting (CAS). In this setting, the order of treatment may impact the clinical outcome in this stroke subtype. Methods: Retrospective analysis was performed on data prospectively collected in 4 international stroke centers between 2013 and 2017. One hundred sixty-five patients with anterior TO were treated by endovascular therapy. Clinical and procedural data were evaluated. Favorable clinical outcome was defined as modified Rankin Scale (mRS) ≤2 at 90 days. Propensity score matching was performed for different treatment strategies. Results: Patients’ mean age was 65 ± 11 years and 118 were male (69%). The median admission National Institutes of Health Stroke Scale was 15 (interquartile range 8). In 59% of the patients (n = 101), the antegrade strategy (first stenting, then thrombectomy) was performed, in 41% (n = 70) retrograde treatment (first thrombectomy, then stenting). Successful reperfusion (mTICI ≥2b) was achieved in 128 patients (75%). Fifty-nine patients (39%) showed a favorable clinical outcome after 90 days. After propensity score matching, data of 100 patients could be analyzed. Analysis revealed that the retrograde strategy yielded a significantly higher rate of successful reperfusion compared to the antegrade strategy (92 vs. 56%; p < 0.001). The rate of favorable clinical outcome after 90 days (mRS ≤2) was consistently higher (44 vs. 30%; p < 0.05) in the retrograde strategy group. Conclusion: Mechanical thrombectomy prior to acute CAS in TO is a predictive factor for favorable clinical outcome at 90 days.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2018

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“…28 Further differences between populations include longer times from symptom onset to groin puncture in the MR CLEAN study and differences in the proportions of patients with diabetes mellitus or atrial fibrillation.…”

Section: December 2016mentioning

confidence: 99%

Clot Burden Score on Baseline Computerized Tomographic Angiography and Intra-Arterial Treatment Effect in Acute Ischemic Stroke

Treurniet¹,

Yoo²,

Berkhemer

et al. 2016

Stroke

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R ecanalization of the occluded vessel is the major focus of modern treatment for acute ischemic stroke. With the accumulating evidence of the additional benefit of intra-arterial treatment (IAT) in patients with anterior circulation acute ischemic stroke, a new era has started in stroke management. [1][2][3][4][5] However, even after IAT, up to 67% of patients with acute Background and Purpose-A high clot burden score (CBS) is associated with favorable outcome after intravenous treatment for acute ischemic stroke. The added benefit of intra-arterial treatment might be less in these patients. The aim of this exploratory post hoc analysis was to assess the relation of CBS with neurological improvement and endovascular treatment effect. Methods-For 499 of 500 patients in the MR CLEAN study (Multicenter Randomized Clinical Trial of EndovascularTreatment for Acute Ischemic Stroke in the Netherlands), the CBS was determined. Ordinal logistic regression models with and without main baseline prognostic variables were used to assess the association between CBS (continuous or dichotomized at CBS of 6) and a shift toward better outcome on the modified Rankin Scale. The model without main baseline prognostic variables only included treatment allocation and CBS. Models with and without a multiplicative interaction term of CBS and treatment were compared using the χ 2 test to assess treatment effect modification by CBS. Results-Higher CBS was associated with a shift toward better outcome on the modified Rankin Scale; adjusted common odds ratio per point CBS was 1.12 (95% confidence interval, 1.04-1.20]. Dichotomized CBS had an adjusted common odds ratio of 1.67 (95% confidence interval, 1.12-2.51). Both effect estimates were slightly attenuated by adding baseline prognostic variables. The addition of the interaction terms did not significantly improve the fit of the models. There was a small and insignificant increase of intra-arterial treatment efficacy in the high CBS group. Conclusions-A higher CBS is associated with improved outcome and may be used as a prognostic marker. We found no evidence that CBS modifies the effect of intra-arterial treatment. Clinical Trial Registration-URL: http://www.trialregister.nl. Unique identifier: NTR1804. URL: http://www.controlledtrials.com. Unique identifier: ISRCTN10888758.

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“…For the studies evaluated in this review, the rate of symptomatic intracranial hemorrhage among patients treated for tandem occlusions ranged from 0%-18% but was not specifically evaluated as a predictor of clinical outcome. 9,11 This risk can be minimized by ensuring a normotensive blood pressure before restoration of flow and following the procedure. As mentioned above, we try to avoid stent placement whenever possible, and the decision of whether or not to use a stent is delayed until after attempts of revascularization of distal occlusions.…”

Section: Discussionmentioning

confidence: 99%

“…Grigoryan et al 9 performed a multivariate analysis and found that the strongest predictor of good outcome in patients with tandem occlusions was young age and low presenting NIHSS score. Reperfusion score of TICI 3 and high ASPECTS (Alberta Stroke Program Early CT Score) at presentation were also found to have a strong association with good clinical outcome.…”

mentioning

confidence: 99%

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

Mbabuike¹,

Gassie²,

Brown³

et al. 2017

FOC

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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.

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Endovascular Treatment of Acute Ischemic Stroke Due to Tandem Occlusions: Large Multicenter Series and Systematic Review

Cited by 72 publications

References 31 publications

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

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

Clot Burden Score on Baseline Computerized Tomographic Angiography and Intra-Arterial Treatment Effect in Acute Ischemic Stroke

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

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