SEIMLESS: Simultaneous Extracranial, Intracranial Management of (tandem) LESsions in Stroke

Abstract

BackgroundPooled individual data from the landmark stroke trials of 2015 conclude that the benefit of endovascular thrombectomy for patients with intracranial arterial occlusion also extends to patients with concomitant (so-called ’tandem') occlusions of proximal vessels. However, there is heterogeneity and debate in the management of these patients, without a clear standard of care. In particular, there is contention regarding whether the proximal or distal lesion should be treated first. We present a case control study and describe the Simultaneous Extracranial, Intracranial Management of (tandem) LESsions in Stroke (SEIMLESS) technique, an efficient approach to the acute ischemic stroke (AIS) patient who presents with tandem lesions (TLs).MethodsWe describe 5 patients, presenting with AIS and TLs between 2015 and 2017, who we treated with SEIMLESS. Cases were reviewed for clinical data, including arterial puncture to intracranial reperfusion, total fluoroscopy time, amount of contrast, age, and gender. Our series was matched to 5 patients treated with the standard ’sequential' approach (angioplasty followed by thrombectomy) in the same time period by the same operator.ResultsArterial access to intracranial recanalization time was significantly shorter in patients treated with SEIMLESS versus those who had angioplasty followed by thrombectomy (39.6±5.9 min vs 85.2±20.6 min; P=0.014). Patients treated ’seimlessly' also received significantly less iodinated contrast (117±13.5 mL vs 213±48.9 mL; P=0.005) and significantly less fluoroscopy time (21.1±5.2 min vs 55.9±17.8 min; P=0.003). There was no difference in the post-procedural Thrombolysis in Cerebral Infarction score for patients treated with SEIMLESS versus the sequential method (p=0.658).ConclusionSEIMLESS is an efficient procedural method that simultaneously treats a distal intracranial occlusion and a more proximal one. Our small case controlled study finds that this technique is feasible and can lead to faster intracranial recanalization compared with the standard ’sequential' method, utilizing less contrast and radiation in the process. Larger studies are needed to verify our findings.

The ReWiSed CARe Technique

“…Both the very high rates of successfully reperfused patients and the short groin to reperfusion times in this study translated into a rate of 48% favorable outcome at discharge and an even higher rate of 55% at 90 days, which is consistent with what has been reported in the literature for the outcome after interventional treatment of AIS caused by TO with rates ranging from 28-60% [4,7,12,13]. A recent case series demonstrated advantages of a simultaneous treatment of proximal ICA lesions with balloon angioplasty in a TO situation; however, only five patients were included and carotid stenting was avoided [15].…”

Technical note on endovascular treatment of concomitant carotid occlusion in large vessel occlusion stroke: The “single-cross” technique

“…Sultan-Qurraie et al describe a similar technique for the treatment of concomitant carotid and intracranial large vessel occlusions 15 although there are some important distinctions to be made between these two techniques. First of all, their SEIMLesS technique recommends advancing the BCG as distally as possible, but it is not reported whether they attempted or were successful in their five-patient retrospective group.…”

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

“…A large prospective study demonstrates that identification of a tandem lesion independently predicts poor response to rt-PA in terms of recanalization (38)(39)(40). While platelet activation is accelerated at the site of ruptured atherosclerotic plaque (18,38), the lack of effect of rt-PA could be related to the fact that most tandem lesions were secondary to atherothrombotic disease of the carotid artery with large clot burden, which is a known predictor of poor recanalization after rt-PA (41)(42)(43). Kim et al supposed that the low recanalization rate may be attributed to the large amount of thrombus (44).…”

“…In terms of carotid atherothrombosis, the presence of a distal MCA occlusion usually is associated to an artery to artery embolism, with a clot proceeding from the carotid plaque which was platelet-rich lyticresistant (41). Despite this, Ali et al confirmed that 30% of the tandem -PAlesions achieved good outcome treated with rt-PA. AIS with tandem lesions should not be used as an exclusion from standard rt-PA therapy within the therapeutic window (18).…”

“…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). None of the studies have focused on mild strokes with tandem lesions.…”