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Author Spotlight: Assessing Ischemic Stroke Damage Through Middle Cerebral Artery Occlusion Model
Published on: August 11, 2023
Emergent Carotid Stenting During Thrombectomy in Tandem Occlusions Secondary to Dissection: A STOP-CAD Secondary
João André Sousa1, Marc Rodrigo-Gisbert2, Liqi Shu3
1Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Unidade Local de Saúde de Coimbra, Portugal (J.A.S., V.B., S.B.-C., J.S.-F.).
Insights
Emergent carotid stenting in acute ischemic stroke with tandem occlusion from cervical artery dissection improved recanalization rates but did not significantly impact functional outcomes or hemorrhage. Further randomized trials are needed to clarify its role.
Area of Science:
- Neurology
- Vascular Surgery
- Interventional Radiology
Background:
- Cervical carotid artery dissection can lead to tandem occlusions, complicating acute ischemic stroke management.
- The optimal endovascular strategy for these complex cases remains debated.
Purpose of the Study:
- To investigate the impact of emergent carotid stenting during endovascular treatment for acute ischemic stroke in patients with tandem occlusion secondary to cervical carotid artery dissection.
Main Methods:
- Secondary analysis of the retrospective international STOP-CAD study.
- Compared outcomes (90-day functional independence, symptomatic intracranial hemorrhage) between patients with and without emergent stenting.
- Assessed procedural success via successful intracranial recanalization using adjusted regression models.
Main Results:
- Emergent stenting was associated with higher rates of successful intracranial recanalization (81.8% vs 76.6%).
- No significant difference in 90-day functional independence (62.0% vs 59.7%) or symptomatic intracranial hemorrhage (7.3% vs 7.9%) was observed.
- Results remained consistent in additional sensitivity analyses.
Conclusions:
- Emergent carotid stenting in this patient group increases successful recanalization but does not improve functional outcomes or safety.
- The causal relationship between stenting and recanalization requires further investigation.
- Randomized controlled trials are necessary to definitively establish the role of emergent stenting.
Background:
The optimal endovascular management of cervical carotid dissection causing tandem occlusion remains uncertain. We investigated the impact of emergent carotid stenting during endovascular treatment for acute ischemic stroke in patients with tandem occlusion secondary to cervical carotid artery dissection.
Methods:
This was a secondary analysis of patients treated with endovascular treatment for acute ischemic stroke due to occlusive carotid artery dissection and tandem occlusion included in the retrospective international STOP-CAD study (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection). We compared patients with and without emergent stenting. The primary efficacy and safety outcomes were 90-day functional independence (modified Rankin Scale score, 0-2) and symptomatic intracranial hemorrhage within 24 hours after endovascular treatment. Procedural outcome was successful intracranial recanalization (modified Thrombolysis in Cerebral Infarction score of 2b/3). We used mixed-effects logistic regression adjusting for site, age, and National Institutes of Health Stroke Scale. In additional analyses, we used inverse probability of treatment weighting and adjusted for Alberta Stroke Program Early CT Score.
Results:
Of the 4023 patients enrolled in STOP-CAD, 328 presented with anterior circulation acute ischemic stroke due to tandem occlusion and underwent endovascular treatment. The median age was 51 (interquartile range, 44-58) years, and 96 patients (29.3%) were female. One hundred fifty patients (45.7%) underwent emergent stenting. There was no significant association between stenting and 90-day functional independence (62.0% versus 59.7%; adjusted odds ratio, 1.23 [95% CI, 0.82-1.86]; P=0.315) or symptomatic intracranial hemorrhage (7.3% versus 7.9%; adjusted odds ratio, 0.95 [95% CI, 0.41-2.2]; P=0.913). Emergent carotid stenting was associated with successful intracranial recanalization (81.8% versus 76.6%; adjusted odds ratio, 2.62 [95% CI, 1.52-4.5]; P<0.001). Results did not meaningfully change in additional analyses.
Conclusions:
In patients presenting with an acute anterior circulation tandem occlusion secondary to cervical carotid artery dissection, emergent stenting was associated with a higher likelihood of successful intracranial recanalization but not improved functional outcomes or increased symptomatic intracranial hemorrhage. It remains unclear whether emergent stenting led to successful intracranial recanalization or patients with successful intracranial recanalization were more likely to be stented. Randomized trials are warranted.
