Endovascular retrograde approach may be a better option for acute tandem occlusions stroke

Abstract

Objective

The endovascular treatment strategy for acute tandem occlusion stroke is challenging, and controversy exists regarding which lesion should be treated first. This study addresses the uncertainty regarding the priority choice for thrombectomy in acute anterior circulation tandem occlusion stroke.

Methods

We analysed the clinical and angiographic data of tandem stroke patients who underwent interventional therapy from the endovAsCular Treatment of acUte Anterior circuLation ischaemic stroke (ACTUAL) registry. Recanalisation was assessed according to the modified thrombolysis in cerebral infarction score. Clinical outcome was evaluated at 90 days using the modified Rankin scale score.

Results

Sixty tandem occlusion stroke patients were enrolled. Thirty-one (51.7%) patients received anterograde therapy, while 29 (48.3%) patients underwent the retrograde approach. Successful recanalisation (modified thrombolysis in cerebral infarction score 2b–3) occurred in 78.3% (47/60) of patients, and 50.0% (30/60) of patients achieved a modified Rankin scale score of 0–2 at 90 days. Patients undergoing the retrograde approach spent less time in distal occlusion recanalisation (125 (86–167) vs. 95 (74–122) minutes; P = 0.04) and achieved better functional outcomes at 90 days (69.0% (20/29) vs. 32.3% (10/31); P = 0.004) than patients who received anterograde therapy. The retrograde approach was associated with favourable clinical outcomes (odds ratio 0.21; 95% confidence interval 0.07–0.64; P = 0.006).

Conclusion

For acute tandem occlusion stroke, favourable outcomes were better in patients undergoing retrograde therapy than in patients who received the anterograde approach. Future randomised trials are warranted to determine the optimal treatment.

Keywords

Tandem occlusion intervention stroke

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References

Adams

Jr Bendixen

Leira

et al.

Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999; 53: 122–125.

Rubiera

Ribo

Delgado-Mederos

et al.

Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke; a journal of cerebral circulation 2006; 37: 2301–2305.

Rubiera

Alvarez-Sabin

Ribo

et al.

Predictors of early arterial reocclusion after tissue plasminogen activator-induced recanalization in acute ischemic stroke. Stroke; a journal of cerebral circulation 2005; 36: 1452–1456.

Campbell

Mitchell

Kleinig

et al.

Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372: 1009–1018.

Bracard

Ducrocq

Mas

et al.

Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 2016; 15: 1138–1147.

Goyal

Demchuk

Menon

et al.

Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372: 1019–1030.

Berkhemer

Fransen

Beumer

et al.

A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372: 11–20.

Saver

Goyal

Bonafe

et al.

Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372: 2285–2295.

Jovin

Chamorro

Cobo

et al.

Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372: 2296–2306.

10.

Rahme

Abruzzo

Ringer

. Acute ischemic stroke in the setting of cervical carotid occlusion: a proposed management strategy. World Neurosurg 2011; 76: S60–S65.

11.

Cohen

Gomori

Rajz

et al.

Emergent stent-assisted angioplasty of extracranial internal carotid artery and intracranial stent-based thrombectomy in acute tandem occlusive disease: technical considerations. J Neurointerv Surg 2013; 5: 440–446.

12.

Rangel-Castilla

Rajah

Shakir

et al.

Management of acute ischemic stroke due to tandem occlusion: should endovascular recanalization of the extracranial or intracranial occlusive lesion be done first?

Neurosurgl Focus 2017; 42: E16.

13.

Lockau

Liebig

Henning

et al.

Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 2015; 57: 589–598.

14.

Mbabuike

Gassie

Brown

et al.

Revascularization of tandem occlusions in acute ischemic stroke: review of the literature and illustrative case. Neurosurg Focus 2017; 42: E15.

15.

Wang

Yang

et al.

Clinical effectiveness and safety outcomes of endovascular treatment for acute anterior circulation ischemic stroke in China. Cerebrovasc Dis 2017; 44: 248–258.

16.

Yang

Hao

et al.

Effect of retrievable stent size on endovascular treatment of acute ischemic stroke: a multicenter study. AJNR Am J Neuroradiol 2017; 38: 1586–1593.

17.

Hong

Saver

. Quantifying the value of stroke disability outcomes: WHO global burden of disease project disability weights for each level of the modified Rankin Scale. Stroke; a journal of cerebral circulation 2009; 40: 3828–3833.

18.

Tomsick

Broderick

Carrozella

et al.

Revascularization results in the Interventional Management of Stroke II trial. AJNR Am J Neuroradiol 2008; 29: 582–587.

19.

von Kummer

Broderick

Campbell

et al.

The Heidelberg Bleeding Classification: classification of bleeding events after ischemic stroke and reperfusion therapy. Stroke; a journal of cerebral circulation 2015; 46: 2981–2986.

20.

Lescher

Czeppan

Porto

et al.

Acute stroke and obstruction of the extracranial carotid artery combined with intracranial tandem occlusion: results of interventional revascularization. Cardiovasc Intervent Radiol 2015; 38: 304–313.

21.

Heck

Brown

. Carotid stenting and intracranial thrombectomy for treatment of acute stroke due to tandem occlusions with aggressive antiplatelet therapy may be associated with a high incidence of intracranial hemorrhage. J Neurointervent Surg 2015; 7: 170–175.

22.

Stampfl

Ringleb

Mohlenbruch

et al.

Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. Am J Neuroradiol 2013; 35: 741–746.

23.

Cohen

Gomori

Rajz

et al.

Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandem occlusive disease. J Neurointervent Surg 2015; 7: 412–417.

24.

Maurer

Joachimski

Berlis

. Two in one: endovascular treatment of acute tandem occlusions in the anterior circulation. Clin Neuroradiol 2014; 25: 397–402.

25.

Christou

Felberg

Demchuk

et al.

Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion. J Neuroimag: Official journal of the American Society of Neuroimaging 2002; 12: 119–123.

26.

Grigoryan

Haussen

Hassan

et al.

Endovascular treatment of acute ischemic stroke due to tandem occlusions: large multicenter series and systematic review. Cerebrovasc Dis 2016; 41: 306–312.

27.

Christoforidis

Karakasis

Mohammad

et al.

Predictors of hemorrhage following intra-arterial thrombolysis for acute ischemic stroke: the role of pial collateral formation. AJNR Am J Neuroradiol 2009; 30: 165–170.

28.

Christoforidis

Vakil

Ansari

et al.

Impact of pial collaterals on infarct growth rate in experimental acute ischemic stroke. AJNR Am J Neuroradiol 2017; 38: 270–275.

29.

Christoforidis

Mohammad

Kehagias

et al.

Angiographic assessment of pial collaterals as a prognostic indicator following intra-arterial thrombolysis for acute ischemic stroke. AJNR Am J Neuroradiol 2005; 26: 1789–1797.

30.

Sivan-Hoffmann

Gory

Armoiry

et al.

Stent-retriever thrombectomy for acute anterior ischemic stroke with tandem occlusion: a systematic review and meta-analysis. Eur Radiol 2017; 27: 247–254.

31.

Behme

Molina

Selim

et al.

Emergent carotid stenting after thrombectomy in patients with tandem lesions. Stroke; a journal of cerebral circulation 2017; 48: 1126–1128.