Management of acute tandem occlusions: Stent-retriever thrombectomy with emergency stenting or angioplasty

Abstract

ObjectiveTo compare outcomes following intracranial stent retriever-based intracranial thrombectomy (SRT) with emergency extracranial internal carotid artery (EICA) stenting or angioplasty alone in patients presenting with acute stroke due to tandem occlusions of the ICA.MethodsConsecutive patients with acute anterior tandem occlusion who received an endovascular intervention within 6h of symptom onset between January 2013 and June 2016 were included in this prospective study. Demographic, radiological, procedural and clinical outcome data were compared between the stenting and the angioplasty alone groups.ResultsOf the 37 patients eligible for the study, 18 had angioplasty alone and 19 underwent stent placement. Successful recanalization rate was statistically significantly higher in the stenting group than in angioplasty alone group (74% vs. 39%) and although not statistically significant, more patients in the stenting group than in the angioplasty alone group had favourable outcomes (63% vs. 50%). There was no significant difference between groups in rates of symptomatic intracranial haemorrhage (SICH), cerebral herniation or mortality.ConclusionThis study in a small sample size suggests that among patients with acute anterior tandem occlusion, SRT with EICA stenting tended to achieve higher recanalization and improved clinical outcomes at three months compared with SRT and angioplasty alone with a similar rate of SICH and mortality.

Comparing Endovascular Treatment Methods in Acute Ischemic Stroke Due to Tandem Occlusion Focusing on Clinical Aspects

“…Only few previous studies investigated the rate of distal embolization according to the interventional technique. Li et al reported that they found higher distal embolic rate in the angioplasty only group [31]. However, occurrence of distal embolization in our study was significantly higher in patients with ACS (39.1% vs. 17.9%, p = 0.043).…”

Antiplatelet therapy within 24 hours of tPA: lessons learned from patients requiring combined thrombectomy and stenting for acute ischemic stroke

“…Antiplatelet strategies by those advocating stenting in this setting typically involve pre-or peri-procedural dual oral antiplatelet or intravenous glycoprotein IIb/IIIa inhibitor loading followed by maintenance therapies, 4)13)34) although holding antiplatelets for 24 hours after tPA despite stent placement has also been described. 22) This latter approach likely derives from the current stroke guidelines that advise against the administration of antiplatelets within 24 hours of tPA, 33) and are based on RCTs that demonstrated increased ICH risk without improved outcomes for the early administration of aspirin after tPA. 41) However, these studies did not account for the increased thrombotic risk in patients undergoing MT or stent placement, a consideration highlighted by the in-stent thrombosis seen in the one patient in this study that had delayed initiation of post-procedural antiplatelets.…”

Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke

“…Successful recanalization rate was statistically significantly higher in the stenting group than in the angioplasty-alone group (74 vs. 39%) and although not statistically significant, more patients in the stent group than in the angioplastyalone group had favorable outcomes (63 vs. 50%). 23 The STRATIS Registry included 147 patients with tandem lesions. Eighty patients underwent carotid stent placement, 43 patients underwent balloon angioplasty, and 24 patients did not undergo angioplasty or stent placement.…”