Head or Neck First? Speed and Rates of Reperfusion in Thrombectomy for Tandem Large Vessel Occlusion Strokes

Abstract

Background: We aim to evaluate the speed and rates of reperfusion in tandem large vessel occlusion acute stroke patients undergoing upfront cervical lesion treatment (Neck-First: angioplasty and/or stent before thrombectomy) as compared to direct intracranial occlusion therapy (Head-First) in a large international multicenter cohort. Methods: The Thrombectomy In TANdem Lesions (TITAN) collaboration pooled individual data of prospectively collected thrombectomy international databases for all consecutive anterior circulation tandem patients who underwent emergent thrombectomy. The co-primary outcome measures were rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) and time from groin puncture to successful reperfusion. Results: In total, 289 patients with tandem atherosclerotic etiology were included in the analysis (182 Neck-First and 107 Head-First patients). Except for differences in the Alberta Stroke Program Early CT Score (ASPECTS; median 8 [range 7–10] Neck-First vs. 7 [range 6–8] Head-First; p < 0.001) and cervical internal carotid artery (ICA) lesion severity (complete occlusion in 35% of the Neck-First vs. 57% of the Head-First patients; p < 0.001), patient characteristics were well balanced. After adjustments, there was no difference in successful reperfusion rates between the study groups (odds ratio associated with Neck-First: 1.18 [95% confidence interval, 0.60–2.17]). The time to successful reperfusion from groin puncture was significantly shorter in the Head-First group after adjustments (median 56 min [range 39–90] vs. 70 [range 50–102]; p = 0.001). No significant differences in the rates of full reperfusion, symptomatic hemorrhage, 90-day independence, or mortality were observed. Sensitivity analysis excluding patients with complete cervical ICA occlusion yielded similar results. Conclusions: The upfront approach of the intracranial lesion in patients with tandem large vessel occlusion strokes leads to similar reperfusion rates but faster reperfusion as compared to initial cervical revascularization followed by mechanical thrombectomy. Controlled studies are warranted.

Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

“…Our finding suggested that the retrograde approach might be superior to the antegrade approach with respect to more and earlier blood restoration and better functional outcome achievable. This was in line with several recent large sample size multicenter studies demonstrating faster distal occlusion reperfusion consistently in better clinical outcomes with the retrograde approach ( 25 , 28 ). Primarily, revascularization of the proximal extracranial lesion with Percutaneous Endovascular Angioplasty (PTA) and/or stenting before distal intracranial occlusion treatment seemed to be time-consuming thus postponed intracranial reperfusion.…”

“…Favorable outcome also reported by all the 11 studies and the pooled results indicated that the retrograde group achieved a significantly better 90-day functional independence than the antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58–0.89, p = 0.002) ( Figure 2B ). Sensitivity analysis indicated the heterogeneity ( p = 0.07, I 2 = 42%) also coming from the aforementioned two articles by Maus et al ( 15 ) and Haussen et al ( 25 ). No publication bias (Begg's test: p = 0.31; Egger's test: p = 0.17) was observed (see online Supplementary File 7 .…”

“…A total of 1,907 articles were initially identified through main electronic database and references of related studies, of which 34 full-text articles were retrieved for assessment after duplicates were removed and title/abstract screened. Eventually, 11 studies that met our inclusion criteria were eligible for final analysis (12)(13)(14)(15)(22)(23)(24)(25)(26)(27)(28). All the included studies had more than one outcome indicator available that was presented separately for comparison analysis between the different treatment strategies.…”

Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Strokes Treated by Thrombectomy: A Review of the TITAN Collaboration

“…Among the patients from the TITAN cohort, order of treatment of intracranial occlusion or cervical occlusion led to a similar rate of successful reperfusion (12). As expected, treating the intracranial occlusion first was associated with faster time from puncture to reperfusion; however, the order of treatment was not associated with clinical outcomes (12).…”

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

“…At present, data regarding antegrade versus retrograde approaches during EVT of TOs in the current literature are limited. 20 In a meta-analysis of CA-and CD-related TOs, no differences in reperfusion rates and clinical outcomes were observed between the antegrade and retrograde EVTs. 2 In line with these findings, no difference in terms of procedural times, number of MT passages, time to recanalization, and final mTICI score were observed between the two approaches in our study.…”