Management of tandem occlusions in acute ischemic stroke – intracranial versus extracranial first and extracranial stenting versus angioplasty alone: a systematic review and meta-analysis

Wilson, Mitchell P; Murad, M. Hassan; Krings, Timo; Pereira, Vítor Mendes; O’Kelly, Cian; Rempel, Jeremy; Hilditch, Christopher Alan; Brinjikji, Waleed

doi:10.1136/neurintsurg-2017-013707

Cited by 125 publications

(119 citation statements)

References 39 publications

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“…It is still controversial whether these extracranial lesions should be managed in the acute setting with angioplasty alone or by stenting 12. Those who argue in favor of angioplasty alone state that the antiplatelet regimen after stent implantation raises the risk of hemorrhagic complications.…”

Section: Discussionmentioning

confidence: 99%

Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study

Aguilar‐Salinas¹,

Agnoletto

Brasiliense

et al. 2018

J NeuroIntervent Surg

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BackgroundTreatment of acute cerebrovascular pathology, such as acute ischemic stroke or intracranial aneurysms, presents a challenge if an extracranial or intracranial stent is required; immediate platelet inhibition is vital. To date, there is no standardized approach for antiplatelet inhibition in an acute setting.ObjectiveTo report our preliminary experience and lessons learnt using cangrelor in acute neurointervention.MethodsA single-arm pilot study was performed to assess the safety and efficacy of cangrelor plus aspirin for platelet inhibition in patients who require acute stenting in the setting of neuroendovascular treatment.ResultsEight patients were enrolled between October 2017 and August 2018. Median age was 71 years (53–86). Seven patients were treated in an acute setting according to the stroke protocol at our institution, while one patient was treated for a symptomatic, unruptured aneurysm with flow diversion and coiling. At admission, the median National Institutes of Health Stroke Scale score for the patients with stroke was 12.5 (range 2–22.3). Cangrelor was infused and all patients achieved adequate platelet inhibition (<200 PRU (P2Y12 reaction units)). Six of seven patients with ischemic stroke had a carotid stent placed and one had an intracranial stent deployed in the middle cerebral artery. None of the patients experienced intraprocedural thromboembolic complications, intraprocedural in-stent thrombosis, hemorrhagic complications, or stroke within 24 hours after the intervention. The majority of patients (6/8) had a good clinical outcome at discharge (modified Rankin Scale score 0–2).ConclusionsOur findings suggest that cangrelor is a promising alternative in acute stenting for the treatment of cerebrovascular pathology. However, further studies with larger samples are required to accurately elucidate its safety and effectiveness in neuroendovascular procedures.

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Section: Discussionmentioning

confidence: 99%

Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study

Aguilar‐Salinas¹,

Agnoletto

Brasiliense

et al. 2018

J NeuroIntervent Surg

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“…Sample sizes were small, and populations were heterogeneous, with the inclusion of dissection-related occlusions in addition to atherosclerotic cervical lesions. A meta-analysis observed no differences in reperfusion rates and clinical outcomes between the groups [13]. However, the methodology did not allow for adjustments for expected baseline clinical imbalances.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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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.

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“…This results in a marked shortening of the procedure time. The mean procedure time for endovascular treatment for TL was reported to be 75-86 minutes, 5,7) but the puncture-to-recanalization time for our patient was…”

Section: Case Presentationmentioning

confidence: 70%

Utility of Coaxial Angioplasty–thrombectomy for Acute Tandem Occlusion of Intracranial and Extracranial Arteries

Miyauchi

Kamiya

Kuriki

et al. 2020

JNET

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We report a novel technique for acute occlusion of both intracranial and extracranial arteries (tandem lesions [TL]). Case Presentation: A 67-year-old male was transferred to our hospital because of right hemiparesis and aphasia. MRA revealed occlusion of the left cervical internal carotid artery (ICA) and middle cerebral artery (MCA). A balloon guide catheter (BGC) was advanced into the left common carotid artery (CCA). A microcatheter was advanced over a microwire through the intracranial thrombus. A stent retriever (SR) was deployed from the MCA to the ICA through the microcatheter. Next, with the SR anchored to the thrombus, the microcatheter was withdrawn. The extracranial percutaneous transluminal angioplasty (PTA) balloon was coaxially advanced over the SR's delivery wire and angioplasty was performed. Then, an aspiration catheter was coaxially advanced to the proximal aspect of the intracranial thrombus over the delivery wire by pump aspiration. We removed the SR and the aspiration catheter as a single unit into the BGC, resulting in sufficient recanalization. The puncture to recanalization time was 29 minutes. Conclusion: This technique can lead to faster recanalization in cases of TL.

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Management of tandem occlusions in acute ischemic stroke – intracranial versus extracranial first and extracranial stenting versus angioplasty alone: a systematic review and meta-analysis

Abstract: Nearly half of all tandem occlusion patients treated with mechanical thrombectomy have good neurological outcomes. No statistical differences in outcome are identified between extracranial first versus intracranial first approaches, nor extracranial stenting versus angioplasty alone.

Cited by 125 publications

References 39 publications

Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study

Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study

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

Utility of Coaxial Angioplasty–thrombectomy for Acute Tandem Occlusion of Intracranial and Extracranial Arteries

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