Treatment of the extracranial carotid artery in tandem lesions during endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis

Abstract

Endovascular treatment (EVT) is the standard treatment for patients with an acute ischemic stroke due to occlusion of large vessel occlusion (LVO). In 20% of patients, concomitant extracranial internal carotid artery (EICA) lesion is present. These tandem lesions (TL) offer a technical challenge. The treatment strategy for the treatment of the ipsilateral EICA is unclear. The aim of this review is to compare two treatment strategies for TL during EVT: balloon angioplasty (BA) only and immediate carotid artery stenting (iCAS). A systematic review and meta-analysis was performed. Data for each included study was extracted. For comparative studies a meta-analysis was performed. Functional outcome was expressed with the modified Rankin scale and safety endpoints were mortality and symptomatic intracranial hemorrhage (sICH). A total of 72 full text articles evaluating treatment of TL during EVT were screened. Sixteen iCAS and five comparative studies were included for meta-analysis. 53% of patients undergoing iCAS during EVT had good functional outcome in comparison to 45% of patients who underwent only BA. Mortality was comparable at 16% for both groups. The incidences of sICH were 8% and 4% for iCAS and BA respectively.In the meta-analysis, iCAS was associated with good functional outcome, with no significant differences in mortality and sICH with compared to BA. This study shows that treatment with iCAS of a simultaneously ipsilateral EICA lesion during EVT is associated with a favorable functional outcome compared to BA only with no significant difference in mortality or sICH. No conclusion could be drawn about the intracranial or extracranial first approach due to scarce of data. More studies are needed to determine long-term neurological outcomes, the necessity of re-interventions and optimal technical approach (intracranial or extracranial first).

Predictors of Good Clinical Outcome After Endovascular Treatment for Acute Ischemic Stroke due to Tandem Lesion in Anterior Circulation: Results from the ASCENT Study

“…We found no association between the early start of DAPT and SICH occurrence (see Results), which was in line with previous finding of no increase in SICH associated with DAPT resulting from recent large meta-analyses [ 14 , 24 ], however, we cannot exclude a potential bias representing by a fact that in some of our patients, the control CT was done earlier than the start of DAPT after EVT, and thus if ICH/SICH was present on control CT, DAPT was not started at all, or antiplatelet monotherapy was used only.…”

Endovascular treatment for acute ischemic stroke in patients with tandem lesion in the anterior circulation: analysis from the METRICS study

“…We did not find a difference in the rate of sICH between patients with prior IVT and with EVT alone (table 2), and the overall rate of sICH (6.2%) was similar to the rates reported from the TITAN and ETIS registry (8.1%)9 and from recent large meta-analysis 18 21. Our findings, as well as those from previous reports, suggest that IVT before EVT seems to be safe,18 22–24 even in patients with TL9 12; however, patients treated with EVT alone may have a lower risk ratio for any type of ICH compared to those treated with bridging therapy 18…”

Carotid Endarterectomy After Intracranial Endovascular Thrombectomy for Acute Ischaemic Stroke in Patients with Carotid Artery Stenosis

“…In a systematic review and meta-analysis of 16 cohort studies of tandem lesion patients treated with EVT and CAS or PTA for concomitant extracranial carotid lesions, the incidence of severe intracranial haemorrhage was 8%. 25 Immediate CAS may not be technically feasible in all patients and CEA may offer an advantage compared with CAS in patients with increased risk of bleeding from DAPT, such as those with a history of gastrointestinal bleeding. In a small series, Singh et al found that emergency CEA had less intracranial haemorrhage than emergency CAS.…”