Acute ischemic stroke with tandem lesions: technical endovascular management and clinical outcomes from the ESCAPE trial

Assis, Zarina; Menon, Bijoy K; Goyal, Mayank; Demchuk, Andrew M.; Shankar, Jai; Rempel, Jeremy; Roy, Daniel; Poppe, Alexander Y; Yang, Victor X. D.; Lum, Cheemun; Dowlatshahi, Dar; Thornton, John; Choe, Hana; Burns, Paul; Frei, Donald; Baxter, Blaise; Hill, Michael D.

doi:10.1136/neurintsurg-2017-013316

Cited by 80 publications

(61 citation statements)

References 17 publications

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“…This might be an explanation for the low potential of rehabilitation in our patients first treated with CAS. Our results are consistent with the observations from the ESCAPE trial sub-analysis, which demonstrated a higher reperfusion rate in subjects whose intracranial occlusion was treated first, followed by the treatment of extracranial lesion compared to the subgroup with reverse sequence of treatment (86 vs. 60%) [5]. The successful reperfusion rate of 92% in our retrograde cohort is superior to available data in the literature that ranges between 70 and 80% for this treatment strategy [9,25].…”

Section: Discussionsupporting

confidence: 79%

“…Other randomized controlled trials (ESCAPE, MR CLEAN, and REVASCAT) included patients with TO with an incidence between 17 and 32% [1,19,20]. Recent subgroup analyses of ESCAPE and MRCLEAN stated that patients with TO should not be deprived of endovascular therapy [4,5]. However, Berkhemer et al [4] treated only 28 out of 81 patients with extracranial carotid disease in the intervention group with CAS, that is, 34.5% of this subgroup.…”

Section: Discussionmentioning

confidence: 99%

“…Specifications about treatment order were not elaborated. Similarly, Assis et al [5] stated that proximal lesions from only 8 out of 30 patients (27%) were managed acutely with CAS. No conclusions could be drawn regarding the superiority of treatment order as only 4 patients were treated in antegrade and retrograde fashion, respectively.…”

Section: Discussionmentioning

confidence: 99%

“…Since the introduction of the new generation of stent retrievers, several studies demonstrated a benefit for this patient cohort after mechanical thrombectomy (MT) and concomitant balloon angioplasty and/or stenting of the extracranial carotid artery disease with rates of favorable clinical outcome up to 68% [3]. The evidence for this combined endovascular treatment in patients with acute TO has recently been verified in sub-group analyses of randomized controlled trials [4,5].…”

Section: Introductionmentioning

confidence: 99%

“…So far, most of the published studies addressing AIS due to TO neither focus on this procedural issue, nor do they show the superiority of one method over the other with regard to clinical outcome, for example, 3 months after stroke [6]. A recent sub-analysis of the ESCAPE trial suggested that TO patients undergoing acute carotid intervention may have a better clinical outcome compared to staged treatment or medical therapy alone [5].…”

Section: Introductionmentioning

confidence: 99%

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Order of Treatment Matters in Ischemic Stroke: Mechanical Thrombectomy First, Then Carotid Artery Stenting for Tandem Lesions of the Anterior Circulation

et al. 2018

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Background: One endovascular treatment option of acute ischemic stroke due to tandem occlusion (TO) comprises intracranial thrombectomy and acute extracranial carotid artery stenting (CAS). In this setting, the order of treatment may impact the clinical outcome in this stroke subtype. Methods: Retrospective analysis was performed on data prospectively collected in 4 international stroke centers between 2013 and 2017. One hundred sixty-five patients with anterior TO were treated by endovascular therapy. Clinical and procedural data were evaluated. Favorable clinical outcome was defined as modified Rankin Scale (mRS) ≤2 at 90 days. Propensity score matching was performed for different treatment strategies. Results: Patients’ mean age was 65 ± 11 years and 118 were male (69%). The median admission National Institutes of Health Stroke Scale was 15 (interquartile range 8). In 59% of the patients (n = 101), the antegrade strategy (first stenting, then thrombectomy) was performed, in 41% (n = 70) retrograde treatment (first thrombectomy, then stenting). Successful reperfusion (mTICI ≥2b) was achieved in 128 patients (75%). Fifty-nine patients (39%) showed a favorable clinical outcome after 90 days. After propensity score matching, data of 100 patients could be analyzed. Analysis revealed that the retrograde strategy yielded a significantly higher rate of successful reperfusion compared to the antegrade strategy (92 vs. 56%; p < 0.001). The rate of favorable clinical outcome after 90 days (mRS ≤2) was consistently higher (44 vs. 30%; p < 0.05) in the retrograde strategy group. Conclusion: Mechanical thrombectomy prior to acute CAS in TO is a predictive factor for favorable clinical outcome at 90 days.

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Section: Discussionsupporting

confidence: 79%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Order of Treatment Matters in Ischemic Stroke: Mechanical Thrombectomy First, Then Carotid Artery Stenting for Tandem Lesions of the Anterior Circulation

et al. 2018

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Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions

et al. 2023

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ImportanceApproximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear.ObjectiveTo evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs.Design, Setting, and ParticipantsThis cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (&gt;50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography.ExposuresPatients with TLs were divided into CAS vs nonstenting groups.Main Outcomes and MeasuresPrimary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days.ResultsOf 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P &lt; .001) and atherosclerotic disease (296 [82.0%] vs 194 [74.6%], P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P &lt; .001), and similar rates of intravenous thrombolysis and stroke time metrics when compared with the nonstenting group. After adjustment for confounders, the odds of favorable functional outcome (adjusted odds ratio [aOR], 1.67; 95% CI, 1.20-2.40; P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups.Conclusions and RelevanceIn this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

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Tandem Occlusion Causing Acute Ischemic Stroke

Rossen

Limaye

Hasan

2019

Acute Stroke Management in the Era of Thrombectomy

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Acute ischemic stroke with tandem lesions: technical endovascular management and clinical outcomes from the ESCAPE trial

Abstract: NCT01778335.

Cited by 80 publications

References 17 publications

Order of Treatment Matters in Ischemic Stroke: Mechanical Thrombectomy First, Then Carotid Artery Stenting for Tandem Lesions of the Anterior Circulation

Order of Treatment Matters in Ischemic Stroke: Mechanical Thrombectomy First, Then Carotid Artery Stenting for Tandem Lesions of the Anterior Circulation

Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions

Tandem Occlusion Causing Acute Ischemic Stroke

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