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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Two in One: Endovascular Treatment of Acute Tandem Occlusions in the Anterior Circulation
C J Maurer1, F Joachimski2, A Berlis3
1Klinik für Neuroradiologie, Universitätsklinik Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany. christoph.johannes.maurer@uniklinik-freiburg.de.
Insights
Mechanical endovascular therapy, including stenting and thrombectomy, offers a safe and effective treatment for acute stroke patients with tandem occlusions. This approach achieves good recanalization rates and satisfactory clinical outcomes.
Area of Science:
- Neurology
- Interventional Neuroradiology
- Vascular Neurology
Background:
- Acute ischemic stroke with tandem occlusions (extracranial internal carotid artery stenosis/occlusion plus intracranial large artery occlusion) presents a treatment challenge.
- Systemic thrombolysis with recombinant tissue plasminogen activator (rtPA) often shows limited efficacy in these complex cases.
- Mechanical endovascular approaches are increasingly utilized for this stroke subtype.
Purpose of the Study:
- To present a single-center cohort of patients with tandem occlusions in the anterior circulation.
- To describe the technical aspects of the combined endovascular procedure.
- To analyze the angiographic and clinical outcomes of this challenging stroke subtype.
Main Methods:
- Retrospective analysis of clinical and imaging data from consecutive patients (July 2008-March 2013).
- Inclusion criteria: intracranial artery occlusion in the anterior circulation with concurrent cervical internal carotid artery (ICA) occlusion or pseudo-occlusion.
- Evaluation of demographical, clinical characteristics, technical approach, recanalization rates, recanalization time, and short-term clinical outcomes.
Main Results:
- 43 patients with anterior circulation tandem occlusions were included.
- The combined endovascular approach involved extracranial stenting/angioplasty and intracranial mechanical thrombectomy.
- Successful angiographic recanalization (Thrombolysis in Cerebral Infarction score 2b or 3) was achieved in 76.7% of cases.
- Mean recanalization time was 103 minutes.
- A modified Rankin Scale score of ≤2 was achieved in 32.6% at discharge.
Conclusions:
- Endovascular therapy for tandem occlusions, combining extracranial stenting and intracranial mechanical thrombectomy, is a safe treatment option.
- This approach can lead to satisfactory angiographic results.
- The procedure may result in favorable short-term clinical outcomes for patients with this complex stroke presentation.
Purpose:
Acute major stroke with high-grade stenosis or occlusion of the extracranial internal carotid artery (ICA) and additional intracranial large artery occlusion is increasingly treated with a mechanical endovascular approach by extracranial stenting and intracranial thrombectomy due to poor response to systemic thrombolysis with recombinant tissue plasminogen activator (rtPA). This article presents a single centre cohort of this challenging subtype of stroke, describing the technical procedure and analysing the angiographic and clinical outcome.
Methods:
Clinical and imaging data of all consecutive patients between July 2008 and March 2013 with intracranial artery occlusion in the anterior circulation and additional occlusion or pseudo-occlusion of the cervical ICA were retrospectively analysed with respect to demographical and clinical characteristics. Technical approach, recanalization rate, recanalization time and short-term clinical outcome were determined.
Results:
A total of 43 patients with tandem occlusion in the anterior circulation met the inclusion criteria. Out of these, 32 (74.4%) occlusions and 11 (25.6%) pseudo-occlusions of the extracranial ICA with additional occlusion of the distal segment of the ICA in 7.0% (3/43), the M1-segment of the middle cerebral artery (MCA) in 81.4% (35/43) or the M2-segment of the MCA in 11.6% (5/43) of cases were treated with combined endovascular approach including extracranial stenting with angioplasty and intracranial mechanical thrombectomy. In 76.7% of cases, an angiographic recanalization result of 2b or 3 using the Thrombolysis in Cerebral Infarction (TICI) score was achieved. Mean time from first angiographic series to recanalization was 103 min. A modified Rankin Scale (mRS) score of ≤ 2 was achieved in 32.6% at the time of discharge.
Conclusion:
Endovascular therapy of patients with tandem occlusion in the anterior circulation with emergency extracranial stenting and intracranial mechanical thrombectomy appears to be safe and may lead to a satisfactory angiographic result and clinical outcome.
