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

Abstract

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.

Interventional Stroke Treatment in Patients with Tandem Lesions: What Factors Influence the Clinical Outcome?

“…Our findings are in most parts in line with the results of other groups [15][16][17][18][19], however, they differ regarding the issue of antegrade versus retrograde stenting. The STRATIS collaboration group [15] demonstrated equipoise concerning antegrade vs. retrograde stenting in a prospective, non-randomized mutlicentric study with 147 patients.…”

“…The STRATIS collaboration group [15] demonstrated equipoise concerning antegrade vs. retrograde stenting in a prospective, non-randomized mutlicentric study with 147 patients. In contrast, Maus, et al analysed the longterm outcome of one hundred patients after endovascular treatment of tandem lesions and found that the retrograde strategy yielded a significantly higher rate of successful reperfusion and a higher rate of favourable clinical outcome after 90 days [16]. This might be explained in parts by a faster recanalization of the intracranial vessel occlusion, when the extracranial stenosis or occlusion of the ICA is initially treated by PTA only.…”

Head or Neck First? Speed and Rates of Reperfusion in Thrombectomy for Tandem Large Vessel Occlusion Strokes

“…Unfortunately, the authors did not adjust for baseline ischemic core size. Recently, a matched analysis of 100 patients demonstrated improved reperfusion rates and clinical outcomes in patients treated with the Head-First as compared to the Neck-Frist approach [14]. …”

Adjustment of Stent Retriever Length to Clot Extent Affects First-Pass Reperfusion in Endovascular Treatment of Acute Ischemic Stroke

“…Our study suggests higher final successful reperfusion rates for long stent retrievers in the anterior circulation and higher final complete reperfusion rates for short stent retrievers in the posterior circulation. Final reperfusion rates are known to be affected by the implementation of various technical maneuvers, device properties, and potential adjuvant techniques [12, 19, 22]; the interpretation of the current results should take this into account, although we tried to balance the analysis by appropriate statistical methods.…”