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Cervical Dissection in Patients With Tandem Lesions Is Associated With Distal Embolism and Lower Recanalization
Milagros Galecio-Castillo1, Waldo R Guerrero2, Ameer E Hassan3
1Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.G.-C., M.F., D.Q.-O., A.R.-C., M.D., S.O.-G.).
Insights
Cervical internal carotid artery dissection in tandem lesions leads to more distal emboli and less successful recanalization compared to atherosclerosis. Minimizing embolism risk may improve outcomes in dissection patients.
Area of Science:
- Neurology
- Vascular Surgery
- Interventional Cardiology
Background:
- Tandem lesions involve cervical internal carotid artery (ICA) stenosis/occlusion plus a large vessel occlusion.
- Etiologies include atherosclerosis and dissection.
- Comparing outcomes between these two etiologies is crucial for stroke management.
Purpose of the Study:
- To compare endovascular treatment outcomes in patients with tandem lesions attributed to cervical ICA atherosclerosis versus dissection.
- To identify specific differences in procedural success and clinical outcomes between the two groups.
Main Methods:
- Multicenter retrospective cohort study of 526 patients undergoing endovascular treatment for tandem lesions (2015-2020).
- Atherosclerosis defined by calcified lesions; dissection by tapered/flame-shaped lesions and intramural hematoma.
- Primary outcome: 90-day functional independence (mRS 0-2); secondary outcomes included recanalization, embolization, and mortality, analyzed using inverse probability of treatment weighting.
Main Results:
- Patients with dissection were younger and had fewer comorbidities but higher rates of ICA occlusion and multiple stents.
- No significant difference in 90-day functional independence between dissection and atherosclerosis groups.
- Dissection group showed significantly lower successful recanalization rates (aOR 0.38) and higher rates of distal emboli (aOR 2.53).
Conclusions:
- Cervical ICA dissection in tandem lesions is associated with increased distal embolism and decreased recanalization success compared to atherosclerosis.
- Techniques to mitigate distal embolism risk may be beneficial for dissection patients.
- Further prospective trials are needed to confirm these findings and guide treatment strategies.
Background:
Tandem lesions consist of cervical internal carotid artery (ICA) stenosis or occlusion, most commonly of atherosclerosis or dissection etiology, plus a large vessel occlusion. In this study, we compare outcomes in patients with atherosclerosis versus dissection of the cervical ICA.
Methods:
This multicenter retrospective cohort study includes data from tandem lesion patients who underwent endovascular treatment from 2015 to 2020. Atherosclerosis was defined as ICA stenosis/occlusion associated with a calcified lesion and dissection by the presence of a tapered or flame-shaped lesion and intramural hematoma. Primary outcome: 90-day functional independence (modified Rankin Scale score, 0-2); secondary outcomes: 90-day favorable shift in the modified Rankin Scale score, modified Thrombolysis in Cerebral Infarction score 2b-3, modified Thrombolysis in Cerebral Infarction score 2c-3, symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, distal embolization, early neurological improvement, and mortality. Analysis was performed with matching by inverse probability of treatment weighting.
Results:
We included 526 patients (68 [59-76] years; 31% females); 11.2% presented dissection and 88.8%, atherosclerosis. Patients with dissection were younger, had lower rates of hypertension, hyperlipidemia, diabetes, and smoking history. They also exhibited higher rates of ICA occlusion, multiple stents (>1), and lower rates of carotid self-expanding stents. After matching and adjusting for covariates, there were no differences in 90-day functional independence. The rate of successful recanalization was significantly lower in the dissection group (adjusted odds ratio, 0.38 [95% CI, 0.16-0.91]; P=0.031), which also had significantly higher rates of distal emboli (adjusted odds ratio, 2.53 [95% CI, 1.15-5.55]; P=0.021). There were no differences in other outcomes. Acute ICA stenting seemed to increase the effect of atherosclerosis in successful recanalization.
Conclusions:
This study reveals that among patients with acute stroke with tandem lesions, cervical ICA dissection is associated with higher rates of distal embolism and lower rates of successful recanalization than atherosclerotic lesions. Using techniques to minimize the risk of distal embolism may mitigate this contrast. Further prospective randomized trials are warranted to fully understand these associations.
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