Endovascular treatment of patients with acute ischemic stroke and tandem occlusion due to internal carotid artery dissection: A multicenter experience

Abstract

Background The optimal management of patients with acute ischemic stroke (AIS) due to tandem occlusion (TO) and underlying carotid dissection (CD) remains unclear. Objective We present our multicenter-experience of endovascular treatment (EVT) approach used and outcomes for AIS patients with CD-related TO (CD-TO). Methods Consecutive AIS patients underwent EVT for CD-TO at five Italian Neuro-interventional Tertiary Stroke Centers were retrospectively identified. TO from atherosclerosis and other causes of, were excluded from the final analysis. Primary outcome was successful (mTICI 2b-3) and complete reperfusion (mTICI 3); secondary outcome was patients’ 3-months functional independence (mRS≤2). Results Among 214 AIS patients with TO, 45 presented CD-TO. Median age was 54 years (range 29–86), 82.2% were male. Age <65 years ( p < 0.0001), lower baseline NIHSS score ( p = 0.0002), and complete circle of Willis ( p = 0.0422) were associated with mRS ≤ 2 at the multivariate analysis. Comparisons between antegrade and retrograde approaches resulted in differences for baseline NIHSS scores ( p = 0.001) and number of EVT attempts per-procedure ( p = 0.001). No differences in terms of recanalization rates were observed between antegrade and retrograde EVT approaches ( p = 0.811) but higher rates of mTICI3 revascularization was observed with the retrograde compared to the antegrade approach (78.6% vs 73.3%), anyway not statistically significant. CD management technique (angioplasty vs aspiration vs emergent stenting) did not correlate with 3-months mRS≤2. Conclusion AIS patients with CD-TO were mostly treated with the retrograde approach with lower number of attempts per-procedure but it offered similar recanalization rates compared with the antegrade approach. Emergent carotid artery stenting (CAS) proved to be safe for CD management but it does not influence 3-months patients’ clinical outcomes.

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data

“…Overall, 71 observational studies were potentially eligible for inclusion, and 34 reached qualitative synthesis (figure 1 for PRISMA flow-chart, online supplemental table 2 for study details). Among them, two observational studies compared noAPT versus SAPT,18 19 three compared noAPT versus DAPT,18 20 21 two compared noAPT versus GPI,18 19 five compared SAPT versus DAPT,18 22–25 four compared SAPT versus GPI18 19 26 27 and four compared DAPT versus GPI,18 28–30 while the remainder focused on a single APT regimen 31–50…”

Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association

“…The majority of multicenter analyses show similar rates of recanalization and symptomatic ICH between the 2 approaches. 83,84 Most studies also report similar 90-day functional outcomes, but 1 retrospective study found better functional outcome with the retrograde approach. 85 Aspiration, angioplasty, and stenting have proved to be successful with equivalent outcomes in retrospective series.…”

“…Although many studies report safety with stenting and even higher rates of vessel patency the day after mechanical thrombectomy, an improvement in functional outcome has not been found. [83][84][85]87,88 In randomized, multicenter studies of extracranial stenting, subgroup analysis of patients with cervical artery dissection failed to show a functional benefit after stent placement. 87,88 However, stenting of a stenotic or occluded dissected segment of the vessel can be considered to improve distal perfusion in patients with neurological deficits due to hypoperfusion.…”

“…85 Aspiration, angioplasty, and stenting have proved to be successful with equivalent outcomes in retrospective series. 83…”