Endovascular treatment of acute ischemic stroke due to tandem lesions of the anterior cerebral circulation: a multicentric Italian observational study

Abstract

Purpose Acute ischemic stroke (AIS) due to tandem lesions (TLs) of extracranial Internal Carotid Artery and Anterior Cerebral Circulation are challenging for endovascular treatment (EVT). This study aims to evaluate feasibility, safety and efficacy of EVT for TLs’ AIS, with or without emergent carotid artery stenting (eCAS), in a real-life scenario. Methods Retrospective review of prospectively collected non-randomized thrombectomy databases from five stroke centers between 2015 and 2019. Consecutive patients with TLs’ AIS were selected. Clinical, neuroimage and procedure features, as well as antiplatelet therapy regimen, were evaluated. Primary outcome was 90-day mRS ≤ 2. Secondary outcomes included: mTICI score 2b-3, extracranial recanalization, procedural complications, symptomatic intracerebral hemorrhage (SICH) and 90-day mortality. Results Two hundred twenty-seven patients were enrolled (67.8% males; mean age 65.9 ± 12.9 years). We obtained mTICI 2b-3 in 77.1%, extracranial recanalization in 86.8%, 90-day mRS (available in 201/227 cases) ≤ 2 in 49.8%. Procedural complications occurred in 16.7%, SICH in 9.7%; 90-day mortality rate (available in 201/227 cases) was 14.4%. The strongest predictors of good clinical outcome were young age (p < 0.0001), low baseline NIHSS (p = 0.008), high baseline ASPECTS (p < 0.0001), good collateral flow (p = 0.013) and extracranial recanalization (p = 0.001). The most significant predictors of SICH were low baseline ASPECTS (p < 0.0001), occurrence of complications (p < 0.0001) and eCAS (p = 0.002). Conclusion In our real-life series, the EVT for TLs’ AIS was feasible, safe and effective in improving 90-day functional outcome with acceptable morbi-mortality rates. ECAS increased the risk of SICH, independently from the antiplatelet therapy regimen.

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

“…Our search detected 1601 citations. Overall, 63 studies were potentially eligible for inclusion, and 46 reached qualitative synthesis11–18 23–60 (figure 1 for PRISMA flow-chart). Among them, 17 observational studies directly compared eCAS and no-stenting, while the remainder focused on a single approach (online supplemental table S1 for included study baseline features).…”

“…Most of the included studies were of moderate to high quality (online supplemental table 1) . The risk of bias was high in some studies, mainly due to ascertainment bias and comparability: 11 studies did not report the intraprocedural or postprocedural medication14 17 25 34 35 44 46 47 49 51 52 (online supplemental figure 1).…”

“…Intraprocedural antiplatelet protocols varied across studies: 15 studies used glycoprotein IIb/IIIa inhibitors (GPI)11 17 18 25 28–31 33 34 37 40 44 48 61 together with the dual antiplatelet therapy after 24 hours, while 13 studies used loading doses of single or dual antiplatelet drugs 4 13 15 23 26 32 36 38 41–43 50 51. Studies using rescue treatment with APTs or GPI after the standard protocol during eCAS were excluded from analysis owing to potential exposure bias 12 16 39 53 59 60.…”

“…Emergent carotid artery stenting (eCAS) is often performed in the context of MT in cases with TO,9 10 even though its safety is unconfirmed. Additionally, the hemorrhagic risk related to periprocedural antithrombotic agents required for eCAS and the risk of early recurrent ischemic events of eCAS and the carotid artery angioplasty (CAA) or no carotid treatment are extremely variable in observational series 11–18…”

What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review

“…Prior IVT (in eligible patients) appears to be safe and to further improve recanalization rates [206,209,210]. Bracco et al [211] have recently reported "hemodynamic" tandem occlusion with an acute total or sub-total occlusion of the extracranial ICA without sufficient collateral compensation. Emergent stenting restoring the antegrade blood flow might be crucial [211].…”