Intra-arterial treatment of patients with acute ischemic stroke and internal carotid artery occlusion: a literature review

Abstract

Introduction Acute ischemic stroke (AIS) due to internal carotid artery (ICA) occlusion has a poor prognosis if treated by intravenous thrombolysis. Intra-arterial (IA) treatment is a promising alternative. However, its effectiveness is still unproven. Methods We collected all publications describing results of IA treatment in acute ICA occlusions. All studies with 10 patients or more providing data on clinical outcome were included. We pooled the results by occlusion site (intracranial, extracranial or tandem occlusions) and treatment method, using recanalization, symptomatic intracranial hemorrhage, mortality and favorable clinical outcome (defined as modified Rankin Scale score 0-2) as outcome measures. Results 32 studies totaling 1107 patients were included. In the population with intracranial ICA occlusion, recanalization (69% vs 38%, p<0.001) and favorable outcome (34% vs 12%, p<0.001) rates were significantly higher for mechanical thrombectomy than for IA thrombolysis. In the population with extracranial ICA occlusion, stenting resulted in a higher recanalization rate (87% vs 48%, p=0.001) and favorable outcome rate (68% vs 15%, p<0.001) and lower mortality (18% vs 41%, p=0.048) than IA thrombolysis. In the tandem occlusion population, a statistically significant lower death rate was found for the group treated with IA thrombolysis only compared with the groups with any mechanical treatment of the intracranial occlusion (0% vs 34%, p=0.002 and 0% vs 33%, p=0.001). Conclusions This review shows that, for patients with AIS due to an extracranial and/or intracranial ICA occlusion, stenting and mechanical thrombectomy are associated with higher recanalization rates and improved functional outcomes compared with IA thrombolysis.

Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study

“…The particular, but not rare, tandem occlusion stroke subtype is still poorly explored. Despite promising results reported in the literature, [13][14][15][16][17][18][19][20][21][22] most of the larger trials available on thrombectomy previously cited [23][24][25] excluded ICD.…”

Thrombectomy in patients with tandem stenoses

“…A recent literature review of 32 studies dealing with endovascular treatment of 1107 patients with acute ischemic stroke and ICA occlusion confirmed these findings [3]. Ten of these studies included patients with tandem occlusions, with an overall favorable clinical outcome in 43 %; however, the mortality rate was 45 %, and 16 % of patients had symptomatic intracranial hemorrhages.…”

“…Ten of these studies included patients with tandem occlusions, with an overall favorable clinical outcome in 43 %; however, the mortality rate was 45 %, and 16 % of patients had symptomatic intracranial hemorrhages. Combined analysis of two studies of patients with tandem occlusions showed a significantly lower death rate for the group treated with intra-arterial thrombolysis and a lower rate of recanalization of the extracranial ICA occlusion (61 % for IA thrombolysis versus 99 % with stenting), whereas the rate of recanalization of intracranial occlusion did not differ significantly (60 versus 78 %) [3].…”

“…Ten of these studies included patients with tandem occlusions, with an overall favorable clinical outcome in 43 %; however, the mortality rate was 45 %, and 16 % of patients had symptomatic intracranial hemorrhages. Combined analysis of two studies of patients with tandem occlusions showed a significantly lower death rate for the group treated with intra-arterial thrombolysis and a lower rate of recanalization of the extracranial ICA occlusion (61 % for IA thrombolysis versus 99 % with stenting), whereas the rate of recanalization of intracranial occlusion did not differ significantly (60 versus 78 %) [3].The current situation regarding thrombolysis treatment is reminiscent of the situation of endovascular treatment of stroke in general, where-fortunately-after a promising start followed by a period of prospective and randomized confusion, the fog is starting to lift.This comment refers to the article available at: http://dx …”

Revascularization of tandem occlusions in acute ischemic stroke: review of the literature and illustrative case

“…For the studies evaluated in this review, the rate of symptomatic intracranial hemorrhage among patients treated for tandem occlusions ranged from 0%-18% but was not specifically evaluated as a predictor of clinical outcome. 9,11 This risk can be minimized by ensuring a normotensive blood pressure before restoration of flow and following the procedure. As mentioned above, we try to avoid stent placement whenever possible, and the decision of whether or not to use a stent is delayed until after attempts of revascularization of distal occlusions.…”