Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Strokes Treated by Thrombectomy: A Review of the TITAN Collaboration

Zhu, François; Bracard, Serge; Anxionnat, René; Derelle, Anne‐Laure; Tonnelet, Romain; Liao, Liang; Mione, Gioia; Humbertjean, Lisa; Lacour, Jean‐Christophe; Hossu, Gabriela; Anadani, Mohammad; Richard, Sébastien; Gory, Benjamin

doi:10.3389/fneur.2019.00206

Cited by 80 publications

(76 citation statements)

References 29 publications

(41 reference statements)

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“…The results support the current guidelines of offering intravenous thrombolysis to eligible patients even if they are being considered for MT (52). TITAN (Thrombectomy in Tandem occlusions) which was a result of a collaborative effort to identify the best therapeutic approach for AIS due to tandem lesions (16), demonstrated that an approach associating emergent carotid stenting with rt-PA in conjunction to thrombectomy may be the best therapeutic option for AIS with tandem lesions leading to higher reperfusion and recanalization rates; this approach was not found to be associated with an increased risk of hemorrhagic complications (39,53,54).…”

Section: Figure 4 |supporting

confidence: 73%

“…Tandem lesions, defined as a combination of high-grade stenosis or occlusion of the internal carotid artery (ICA) with concomitant occlusion of an intracranial vessel (14,15), accounted for about 10-15% of AIS due to large-artery atherosclerosis (LAA) (16). The treatment of AIS with tandem lesions remains a unique technical challenge due to the low recanalization rate and poor outcomes after rt-PA (17,18).…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion

Wei

Zhang

et al. 2020

Front. Neurol.

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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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Section: Figure 4 |supporting

confidence: 73%

Section: Introductionmentioning

confidence: 99%

Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion

Wei

Zhang

et al. 2020

Front. Neurol.

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“…Among the patients from the TITAN cohort, the order of treatment of intracranial occlusion or cervical occlusion led to a similar rate of successful reperfusion. 19 As expected, treating the intracranial occlusion first was associated with faster time from puncture to reperfusion; however, the order of treatment was not associated with clinical outcomes.…”

Section: Which Occlusion Should Be Treated First?mentioning

confidence: 54%

Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke

Gemmete

Wilseck

Pandey

et al. 2020

Semin intervent Radiol

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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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“…However, this study had a single-center retrospective design, and the sample size was small (24 patients) in the emergent stenting group [18]. Notably, TITAN study did not find a definite association between extracranial ICA stenting and post-procedural hemorrhage, although procedure-related complications after 90 days of EVT, including any ICH, were lower in the intracranial thrombectomy with ICA stenting group than in the intracranial thrombectomy only group [19]. However, while final successful reperfusion rate was similar between ES and NES groups in the current study, reperfusion success rate was significantly higher in the ICA stenting group than thrombectomy only group in the TITAN study.…”

Section: Discussionmentioning

confidence: 99%

Clinical Impact of Intracerebral Hemorrhage after Hyperacute Extracranial Stenting in Patients with Ischemic Stroke

et al. 2019

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PurposeEmergent intracranial occlusions causing acute ischemic stroke are often related to extracranial atherosclerotic stenosis. This study aimed to investigate the association between post-procedure intracerebral hemorrhage (ICH) and emergent extracranial artery stenting and assess their effects on clinical outcomes in patients with acute ischemic stroke.Materials and MethodsWe retrospectively analyzed patients undergoing hyperacute endovascular treatment for cervicocephalic vascular occlusion in three Korean hospitals between January 2011 and February 2016. Patients who had extracranial artery involvement and were treated from 24 hours of symptom onset to puncture were included in this study, and they were divided into the extracranial stenting (ES) and non-ES groups. Any type of petechial hemorrhages and parenchymal hematoma was defined as ICH for the current study.ResultsIn total, 76 patients were included in this study. Among them, 56 patients underwent ES, and 20 patients did not. Baseline characteristics, risk factors, laboratory data, treatment methods, successful reperfusion rates, and baseline stenotic degrees of extracranial internal carotid artery did not differ between these two groups. However, atrial fibrillation was more frequent in patients without than with ES (P=0.002), and post-procedure ICH was more frequent in patients with than without ES (P=0.035). Logistic regression models revealed that ES was independently associated with post-procedure ICH (odds ratio [OR], 7.807; 95% confidence interval [CI], 1.213–50.248; P=0.031), and ICH was independently associated with poor clinical outcomes (OR, 0.202; 95% CI, 0.054–0.759; P=0.018); however, ES itself was not associated with clinical outcomes (OR, 0.530; 95% CI, 0.117–2.395; P=0.409). Notably, ICH and ES had interaction for predicting good outcomes (P=0.041).ConclusionPost-procedure ICH was associated with ES and poor clinical outcomes. Therefore, ES should be cautiously considered in patients with hyperacute stroke.

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Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Strokes Treated by Thrombectomy: A Review of the TITAN Collaboration

Cited by 80 publications

References 29 publications

Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion

Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion

Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke

Clinical Impact of Intracerebral Hemorrhage after Hyperacute Extracranial Stenting in Patients with Ischemic Stroke

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