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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Endovascular treatment of tandem vascular occlusions in acute ischemic stroke
Ajit S Puri1, Anna L Kühn1, Hyon-Jo Kwon2
1Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA.
Insights
Tandem occlusions causing acute ischemic stroke (AIS) were treated with stenting and revascularization. This approach successfully opened blocked arteries and improved patient outcomes with few complications.
Area of Science:
- Neurology
- Vascular Surgery
- Interventional Radiology
Background:
- Tandem vascular occlusions are a significant cause of acute ischemic stroke (AIS).
- These occlusions present complex treatment challenges due to combined extracranial and intracranial blockages.
Observation:
- Twenty-eight AIS patients with tandem occlusions (extracranial and intracranial) were analyzed.
- The majority (89.3%) had carotid artery and middle cerebral artery occlusions.
- An antegrade approach, treating the extracranial lesion first with a stent, was preferred.
Findings:
- Successful recanalization of proximal occlusions was achieved in 96.4% of patients, primarily using stents.
- Intracranial revascularization resulted in Thrombolysis In Cerebral Infarction (TICI) scores of ≥ 2A in 96.4% of cases.
- A modified Rankin Scale (mRS) score of ≤ 2 at 90 days was achieved in 56.5% of patients.
Implications:
- This approach of stenting proximal occlusions followed by distal revascularization demonstrates a viable strategy for managing tandem occlusions in AIS.
- The technique is associated with low periprocedural complications and offers excellent angiographic and clinical outcomes.
- Further research can validate these findings in larger cohorts.
Background And Purpose:
Tandem vascular occlusions are an important cause of acute ischemic stroke (AIS) and present unique treatment challenges. We report our experience of managing a subset of AIS patients with extracranial vascular stenting/angioplasty and intracranial revascularization.
Methods:
Consecutive patients who presented at three centers with AIS from tandem vascular occlusions confirmed by brain and neck CT imaging were included in the study. We retrospectively analyzed the patient demographics, National Institute of Health Stroke Scale (NIHSS) score and modified Rankin Scale (mRS) score at the time of admission, treatment strategy, angiographic results using the Thrombolysis In Cerebral Infarction (TICI) score, and clinical and imaging follow-up.
Results:
Twenty-eight patients were included. The mean NIHSS score at admission was 18. Extracranial carotid occlusions with a concomitant middle cerebral artery occlusion were seen in 89.3% of patients (n=25) and vertebral artery combined with basilar artery lesions in 10.7% (n=3). An antegrade approach (ie, treatment of the extracranial lesion first) was used in 24 patients (85.7%). Proximal occlusion recanalization was achieved usually with a stent (n=27; 96.4%). Pursuant to intracranial revascularization techniques, ≥ TICI 2A recanalization was seen in 96.4% of patients. An mRS score of ≤ 2 at 90 days was achieved in 56.5% of patients.
Conclusions:
Our study shows preliminary data from three centers on recanalization of tandem occlusions in patients presenting with AIS. There was a preference to revascularize the proximal occlusion using a stent followed by distal recanalization with mechanical thrombectomy, intra-arterial thrombolysis or a combination of these. This approach has low periprocedural complications and can achieve an excellent angiographic and clinical outcome.
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