Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

Abstract

Background:Systemic intravenous thrombolysis and mechanical thrombectomy (MT) are guideline-recommended reperfusion therapies in large-vessel-occlusion ischemic stroke. However, for acute ischemic stroke of extracranial carotid artery origin (AIS-CA) there have been no specific trials, resulting in a data gap. Material/Methods:We evaluated referral/treatment pathways, serial imaging, and neurologic 90-day outcomes in consecutive patients, presenting in a real-life series in 2 stroke centers over a period of 6 months, with AIS-CA eligible for emergency mechanical reperfusion (EMR) on top of thrombolysis as per guideline criteria. Results:Of 30 EMR-eligible patients (33.3% in-window for thrombolysis and thrombolysed, 73.3% male, age 39-87 years, median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 10, pre-stroke mRS 0-1 in all, tandem lesions 26.7%), 20 (66.7%) were EMR-referred (60% -endovascular, 6.7% -surgery referrals). Only 40% received EMR, nearly exclusively in stroke centers with carotid artery stenting (CAS) expertise (100% eligible patient acceptance rate, 100% treatment delivery involving CAS±MT with culprit lesion sequestration using micronet-covered stents). The emergency surgery rate was 0%. Baseline clinical and imaging characteristics did not differ between EMR-treated and EMR-untreated patients. Ninety-day neurologic status was profoundly better in EMR-treated patients: mRS 0-2 (91.7% vs 0%; P<0.001); mRS 3-5 (8.3% vs 88.9%; P<0.001), mRS 6 (0% vs 11.1%; P<0.001). Conclusions:In a real-life AIS-CA setting, the referral rate of EMR-eligible patients for EMR was low, and the treatment rate was even lower. AIS-CA revascularization was delivered predominantly in stroke thrombectomy-capable cardioangiology centers, resulting in overwhelmingly superior patient outcome. Large vessel occlusion stroke referral and management pathways should involve centers with proximal-protected CAS expertise. AIS-CA, irrespective of any thrombolysis administration, is a hyperacute cerebral emergency and EMR-eligible patients should be immediately referred for mechanical reperfusion.

Carotid Stenosis and Stroke: Medicines, Stents, Surgery—“Wait-and-See” or Protect?

“…20 89 Recent evidence indicates that less than 20 unselected patients with a significant carotid stenosis need to be revascularized (number-needed-to-revascularize (NNR)) to prevent one stroke. 111 112 NNR is likely to be significantly lower in patients with increased lesion-level and/or clinical risk features. 19 20 39 51 53 54 63 69 That said, the cardinal principle for any preventive therapy (including carotid revascularization to reduce stroke risk) is that the benefit must outweigh the risk.…”

“…20 Patients in at-risk population categories deserve comprehensive information in reaching treatment decisions about therapies designed to prevent stroke. 20 112 113 114 115 116 117 Patients in at-risk categories deserve comprehensive information to assist in treatment decisions regarding therapies designed to prevent stroke. 20 Patient preference typically and overwhelmingly is to receive preventive treatment for stroke which is effective in both short and long term and delivered with a low procedural risk and with least invasiveness.…”

World Federation for Interventional Stroke Treatment (WIST) multispecialty training guidelines for endovascular stroke intervention

“…Carotid artery thrombectomy and stenting including familiarity with proximal and distal protection, stent designs, balloon angioplasty, thrombectomy catheters, and complication recognition and management [ 38 ].…”