Carotid Stenting and Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Tandem Occlusions: Antithrombotic Treatment and Functional Outcome

Abstract

BACKGROUND AND PURPOSE: There is no consensus on the optimal antithrombotic medication for patients with acute ischemic stroke with anterior circulation tandem occlusions treated with emergent carotid stent placement and mechanical thrombectomy. The identification of factors influencing hemorrhagic risks can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to investigate the impact of medical therapy on functional and safety outcomes in patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions. MATERIALS AND METHODS:A multicenter retrospective study on prospectively collected data was conducted. Only patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions of the anterior circulation were included. Univariate and multivariate analyses were performed on preprocedural, procedural, and postprocedural variables to assess factors influencing clinical outcome, symptomatic intracranial hemorrhage, stent patency, and successful intracranial vessel recanalization.RESULTS: Ninety-five patients with acute ischemic stroke and tandem occlusions were included. Good clinical outcome (mRS # 2) at 3 months was reached by 33 (39.3%) patients and was associated with baseline ASPECTS $ 8 (OR ¼ 1.53; 95% CI, 1.16-2.00), #2 mechanical thrombectomy attempts (OR ¼ 0.71; 95% CI, 0.55-0.99), and the absence of symptomatic intracranial hemorrhage (OR ¼ 0.13; 95% CI , 0.03-0.51). Symptomatic intracranial hemorrhage was associated with a higher amount of intraprocedural heparin, ASPECTS # 7, and $3 mechanical thrombectomy attempts. No relationships among types of acute antiplatelet regimen, intravenous thrombolysis, and symptomatic intracranial hemorrhage were observed. Patients receiving dual-antiplatelet therapy after hemorrhagic transformation had been ruled out on 24-hour CT were more likely to achieve functional independence and had a lower risk of symptomatic intracranial hemorrhage.CONCLUSIONS: During carotid stent placement and mechanical thrombectomy for tandem occlusion treatment, higher intraprocedural heparin dosage ($3000 IU) increased symptomatic intracranial hemorrhage risk when the initial ASPECTS was #7, and mechanical thrombectomy needs more than one passage for complete recanalization. Antiplatelets antiplatelets use were safe, and dual-antiaggregation therapy was related to better functional outcomes.

Mechanical thrombectomy in acute ischemic stroke with tandem occlusions: impact of extracranial carotid lesion etiology on endovascular management and outcome

“…26 In a study recently reported by our group, we found that emergency stenting is safer in defined circumstances, including intraprocedural heparin avoidance, baseline ASPECTS > 8, and a straightforward MT with a first-pass complete recanalization. 27 In the present study, we confirmed the safety and efficacy of emergency stenting in TOs irrespective of ECL etiology, without differences in terms of sICH risk between the two groups. However, we found that only patients with CA-related TOs showed a better 3-month outcome after emergency stenting.…”

Endovascular treatment for acute ischemic stroke in patients with tandem lesion in the anterior circulation: analysis from the METRICS study

“…A previous report showed that a heparin dose of 3000 IU administered during the EVT intervention for TL was a significant predictor of sICH,25 while in our study patients did not receive heparin during the EVT.…”

Comparing Endovascular Treatment Methods in Acute Ischemic Stroke Due to Tandem Occlusion Focusing on Clinical Aspects

“…Based on the latest antiplatelet Delphi consensus, aspirin IV (500 mg bolus) should be used as the first-line agent prior to carotid stenting [22]. Although Da Ros et al identified potential predictors for sICH as the higher intraprocedural heparin dosage, the initial ASPECTS ≤7 and the MT needs more than one attempt for complete recanalization [26]. However, differences were not observed in our study, probably due to the significantly lower number of sICH cases, the different periprocedural heparin management, and the lack of detailed MT attempts data (only the presence of first pass effect was documented).…”