Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke

Gemmete, Joseph J.; Wilseck, Zachary M.; Pandey, Aditya S.; Chaudhary, Neeraj

doi:10.1055/s-0040-1709207

Cited by 5 publications

(5 citation statements)

References 52 publications

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“…The current 2019 AHA/ASA guidelines on endovascular treatment of TO recommend EVT with recanalization of both extracranial and intracranial occlusions (class IIb, level B-R) [ 8 ]. However, the technical approach, timing in the treatment of cICA and medical management are still unsettled [ 8 , 9 ]. More information is needed to increase the chances of better outcome and reduce serious adverse events such as symptomatic intracranial hemorrhage (sICH), embolization in new territories and stent thrombosis.…”

Section: Introductionmentioning

confidence: 99%

Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis

Enriquez

Nome

et al. 2023

BMC Neurol

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Background The endovascular treatment procedure in tandem occlusions (TO) is complex compared to single occlusion (SO) and optimal management remains uncertain. The aim of this study was to identify clinical and procedural factors that may be associated to efficacy and safety in the management of TO and compare functional outcome in TO and SO stroke patients. Methods This is a retrospective single center study of medium (MeVO) and large vessel occlusion (LVO) of the anterior circulation. Clinical, imaging, and interventional data were analyzed to identify predictive factors for symptomatic intracranial hemorrhage (sICH) and functional outcome after endovascular treatment (EVT) in TO. Functional outcome in TO and SO patients was compared. Results Of 662 anterior circulation stroke patients with MeVO and LVO stroke, 90 (14%) had TO. Stenting was performed in 73 (81%) of TO patients. Stent thromboses occurred in 8 (11%) patients. Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 82 (91%). SICH occurred in seven (8%). The strongest predictors for sICH were diabetes mellitus and number of stent retriever passes. Good functional clinical outcome (mRS ≤ 2) at 90-day follow up was similar in TO and SO patients (58% vs 59% respectively). General anesthesia (GA) was associated with good functional outcome whereas hemorrhage in the infarcted tissue, lower mTICI score and history of smoking were associated with poor outcome. Conclusions The risk of sICH was increased in patients with diabetes mellitus and those with extra stent-retriever attempts. Functional clinical outcomes in patients with TO were comparable to patients with SO.

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Section: Introductionmentioning

confidence: 99%

Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis

Enriquez

Nome

et al. 2023

BMC Neurol

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“…[17][18][19] It has been well known that there are several theoretic advantages of anterograde technology, including increase in distal perfusion from collaterals following improvement in proximal flow, decrease in risk of vessel dissection or perforation by nonblind navigation of the ICA, and better accessibility of intracranial lesions for effective treatment with thrombectomy device. 20 However, disadvantages of this technique include the distal migration of the intracranial thrombus provoked by re-established anterograde carotid flow, potential snagging of the retrievable stent in the struts of an already-deployed extracranial ICA stent, and potential hemodynamic instability due to baroreceptor activation. 14,[20][21][22][23] The advantage to retrograde stent approach is a shorter intracranial recanalization time while avoiding the disadvantages of anterograde technology, but this is only if the cervical ICA lesion can be crossed.…”

Section: Introductionmentioning

confidence: 99%

“…20 However, disadvantages of this technique include the distal migration of the intracranial thrombus provoked by re-established anterograde carotid flow, potential snagging of the retrievable stent in the struts of an already-deployed extracranial ICA stent, and potential hemodynamic instability due to baroreceptor activation. 14,[20][21][22][23] The advantage to retrograde stent approach is a shorter intracranial recanalization time while avoiding the disadvantages of anterograde technology, but this is only if the cervical ICA lesion can be crossed. 14,[20][21][22][23] Thus, the strategy of passing the extracranial ICA lesion is the key process but has not been well resolved in retrograde approach.…”

Section: Introductionmentioning

confidence: 99%

“…14,[20][21][22][23] The advantage to retrograde stent approach is a shorter intracranial recanalization time while avoiding the disadvantages of anterograde technology, but this is only if the cervical ICA lesion can be crossed. 14,[20][21][22][23] Thus, the strategy of passing the extracranial ICA lesion is the key process but has not been well resolved in retrograde approach. At present, optimal strategies for acute tandem occlusions stroke remain yet to be elucidated with both anterograde and retrograde angioplasty or stent being options.…”

Section: Introductionmentioning

confidence: 99%

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Passing Extracranial Artery Occlusion by Intermediate Catheter With Expanding Microballoon (PEACE): A Novel Endovascular Therapy in Acute Tandem Occlusion Stroke

et al. 2021

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Purpose: Endovascular treatment of atherosclerotic tandem occlusions in acute ischemic stroke (AIS) is a matter of debate. This article reports a single-center experience using an intermediate catheter with microballoon for treatment of tandem occlusions. Methods: A total of 151 AIS patients with large vessel occlusion received endovascular therapy and a consecutive series of patients (n = 26) who suffered from tandem cervical intracranial occlusions were treated using the Passing Extracranial Artery Occlusion by Intermediate Catheter with Expanding Microballoon (PEACE) technique. Intracranial recanalization was achieved by aspiration or stent retriever and then emergency stenting was performed for extracranial internal carotid artery (ICA) lesion. Demographic, clinical characteristics, procedural details of endovascular therapy, and prognosis outcome were assessed. The outcomes of tandem occlusion group were compared with isolated intracranial occlusion group (n = 122) and previous studies. Results: As compared to isolated intracranial occlusion groups, only a few patients suffered from atrial fibrillation (7.7% vs 38.5%, p<0.01) in tandem occlusions group. A larger proportion of patients (61.5% vs 29.5%) had tandem occlusions in which extracranial ICA occlusion was combined with intracranial terminus occlusion in ICA (p<0.01). 46.2% of tandem occlusions patients achieved intracranial recanalization by aspiration alone versus 15.6% in patients with isolated intracranial occlusion (p<0.01). In tandem occlusion patients treated with PEACE, 92.3% achieved successful reperfusion (thrombolysis in cerebral infarct [TICI] ≥2b). The median time from puncture to recanalization was 51 minutes (interquartile range [IQR], 41–66). 67.6% favorable functional prognosis (modified Rankin score [mRS], 0–2) was seen, with 11.5% mortality and 3.8% of symptomatic intracerebral hemorrhage (sICH) at 90 days. These outcomes are all consistent or better than previously reported studies performed for tandem occlusion. Conclusions: Endovascular therapy using the PEACE technique with intermediate catheter and lined expanding microballoon is safe, efficient, and fast in the treatment of atherosclerotic tandem occlusion patients.

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“…The current 2019 AHA/ASA guidelines on endovascular treatment of TO recommend EVT with recanalization of both extracranial and intracranial occlusions (class IIb, level B-R) [8]. However, the technical approach, timing in the treatment of cICA and medical management are still unsettled [8,9]. More information is needed to increase the chances of better outcome and reduce serious adverse events such as symptomatic intracranial hemorrhage (sICH), embolization in new territories and stent reocclusions.…”

mentioning

confidence: 99%

Predictors of outcome after endovascular treatment for Tandem Occlusions: a single center retrospective analysis

Enriquez

Nome

et al. 2022

Preprint

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Background The endovascular treatment procedure in tandem occlusions (TO) is complex compared to single occlusion (SO) and optimal management remains uncertain. The aim of this study was to identify clinical and procedural factors that may be associated to efficacy and safety in the management of TO and compare functional outcome in TO and SO stroke patients. Methods This is a prospective, observational single center study of medium (MeVO) and large vessel occlusion (LVO) of the anterior circulation. Clinical, imaging, and interventional data were analyzed to identify predictive factors for symptomatic intracranial hemorrhage (sICH) and functional outcome after endovascular treatment (EVT). Functional outcome in TO and SO patients was compared. Results Of 662 anterior circulation stroke patients with MeVO and LVO stroke, 90 (14%) had TO. Stenting was performed in 73 (81%) of TO patients. Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 82 (91%). SICH occurred in seven (8%). The strongest predictors for sICH were diabetes mellitus and number of stent retriever passes. Good functional clinical outcome (mRS ≤ 2) at 90-day follow up was similar in TO and SO patients (58% vs 59% respectively). General anesthesia (GA) was associated with good functional outcome whereas hemorrhage in the infarcted tissue, lower mTICI score and history of smoking were associated with poor outcome. Conclusions The risk of sICH was increased in patients with diabetes mellitus and those with extra stent-retriever attempts. Functional clinical outcomes in patients with TO were comparable to patients with SO.

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Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke

Cited by 5 publications

References 52 publications

Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis

Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis

Passing Extracranial Artery Occlusion by Intermediate Catheter With Expanding Microballoon (PEACE): A Novel Endovascular Therapy in Acute Tandem Occlusion Stroke

Predictors of outcome after endovascular treatment for Tandem Occlusions: a single center retrospective analysis

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