Functional Outcome and Safety of Intracranial Thrombectomy After Emergent Extracranial Stenting in Acute Ischemic Stroke Due to Tandem Occlusions

Abstract

Background and Purpose: Various endovascular approaches to treat acute ischemic stroke caused by extra- intracranial tandem occlusions (TO) exist: percutaneous transluminal angioplasty with or without emergent extracranial carotid stenting (ECS) due to high-grade stenosis preceded or followed by intracranial mechanical and/or aspiration thrombectomy (MT). Which treatment strategy to use is still a matter of debate.Methods: From our ongoing prospective stroke registry we retrospectively analyzed 1,071 patients with anterior circulation stroke getting endovascular treatment within 6 h of symptom onset. ECS prior to intracranial MT for TO (n = 222) was compared to MT as standard of care (control group; acute intracranial vessel occlusion without concomitant ipsilateral ICA-occlusion or high-grade stenosis [C; n = 849]). Good functional outcome (mRS ≤ 2 at 3 months), mortality rates, frequencies of symptomatic intracranial hemorrhage (sICH) and successful recanalization (Thrombolysis in Cerebral Infarction Score [TICI] 2b or 3) were assessed. In subgroup analyses we tried to detect possible influences of stroke etiology, dual inhibition of platelet aggregation (IPA; clopidogrel [CLO]: n = 83; ticagrelor [TIC]: n = 137; in combination with Aspirin) and intravenous thrombolysis (IVT).Results: Functional outcome was superior in TO (mRS 0–2: 44.6%) when compared with controls (36.0%; OR [95% CI]: 3.49 [1.59–7.67]; p = 0.002). There was no difference in all-cause mortality at 3 months (TO: 21.6%; C: 27.7%; 0.78 [0.47–1.29]; p = 0.324), in-hospital mortality (0.76 [0.45–1.30]; p = 0.324), sICH (TO: 3.2%; C: 5.0%; 0.70 [0.30–1.59]; p = 0.389), and TICI 2b/3 (TO: 89.1%; C: 88.3%; p = 0.813). In subgroup-analysis, TIC and CLO did not differ in functional outcome (TIC: 45.3%; CLO: 44.6%; 1.04 [0.51–2.09]; p = 0.920) and mortality rates (all-cause mortality: TIC: 23.4%; CLO: 16.9%; 0.75 [0.27–2.13]; p = 0.594). sICH was more frequent in TIC (n = 7 [5.1%]) vs. CLO (n = 0; p = 0.048).Conclusion: In our pre-selected cohort, ECS prior to intracranial MT in TO allowed for a good functional outcome that was superior compared to a control population. Mortality rates did not differ. Despite a dual IPA in TO, there was no increase in sICH. CLO and TIC for dual IPA did not differ in terms out outcome and mortality rates. A significant increase in sICH was observed after initial loading with TIC.

Endovascular Treatment With and Without Intravenous Thrombolysis in Large Vessel Occlusions Stroke: A Systematic Review and Meta-Analysis

“…sICH, symptomatic intracranial hemorrhage; ICA, internal carotid artery. *The acute intracranial vessel occlusion patients with (a) or without (b) concomitant ipsilateral ICA-occlusion or high-grade stenosis were investigated respectively in the study by Bücke et al ( 22 ).…”

Treatment of the extracranial carotid artery in tandem lesions during endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis

“…After evaluation of the titles and abstracts, 72 articles were selected for fulltext assessment. Twenty-one studies met our inclusion criteria for this literature review (7,(14)(15)(16)(17)24,25,(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42). Most frequent reason for exclusion (n=37) of an article was that data was not presented separately on outcome for the different treatment options or insufficiently reported.…”

“…EVT results in a higher recanalization rate and better functional outcomes than IVT alone and has been rapidly implemented in to national stroke guidelines and standard clinical care (3)(4)(5). For patients with a concomitant EICA lesion, EVT has also been shown to contribute to good functional outcome (6,7). In those patients with a significant EICA stenosis, a balloon angioplasty (BA) is performed in order gain access to the intracerebral vessels for thrombectomy.…”

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

“…Furthermore, currently there is no consensus on the ideal technical interventional strategy. Multiple endovascular treatment strategies have been described: balloon angioplasty with or without emergent carotid artery stenting of the extracranial ICA (EICA) preceded or followed by MT [15]. However, the appropriate patient population for the different endovascular strategies are still unclear [16][17][18][19].…”