Clinical Neuroradiology

, Volume 23, Issue 3, pp 207–215 | Cite as

Clinical Outcome of Neurointerventional Emergency Treatment of Extra- or Intracranial Tandem Occlusions in Acute Major Stroke: Antegrade Approach With Wallstent and Solitaire Stent Retriever

Original Article



Acute large cerebral artery occlusions respond poorly to systemic thrombolysis with recombinant tissue plasminogen activator (rTPA) alone. The value of stent retriever–based mechanical thrombectomy in patients with additional extracranial occlusion of the internal carotid artery (ICA), who require acute a priori extracranial stenting in order to reach the intracranial obstruction site, is not well known. We determined the outcome after emergency revascularization in acute stroke with tandem occlusions of the anterior circulation.


According to specific inclusion/exclusion criteria, eligible stroke patients with large artery occlusions underwent mechanical recanalization with the Solitaire stent retriever. In case of a tandem occlusion, we performed an acute stenting with the Wallstent before thrombectomy. From October 2009 to March 2011, 50 patients were treated according to this protocol; time frames, clinical data, recanalization rates, and midterm outcome were recorded.


Forty-one patients had a large artery occlusion in the anterior circulation and nine in the posterior circulation. Mechanical recanalization was successful in 35/41 cases (85 %). Six of 41 patients (15 %) died in the acute phase. In 17/41 patients (42 %), thrombectomy was preceded by an emergency stenting in the extracranial portion of the internal carotid artery (ICA). National Institutes of Health Stroke Scale (NIHSS)/modified Rankin Scale (mRS) scores showed significant improvement in both the stenting group and the nonstenting group; there were no significant differences between the groups. At 90 days, 54 % of patients with emergency stenting had a good outcome.


Acute extracranial stenting with the Wallstent combined with intracranial Solitaire-based thrombectomy is safe and may lead to an improvement in neurological outcome in patients with an otherwise poor prognosis under i.v. thrombolysis alone.


Acute stroke Mechanical thrombectomy Acute stenting Solitaire Stent retriever Tandem occlusion 



Vertebral artery


Posterior cerebral artery


Basilar artery


Thrombolysis in myocardial infarction


Time interval from onset to recanalization


Symptomatic intracranial hemorrhage

Klinische Ergebnisse der neurointerventionellen Akutbehandlung extra-/intrakranieller Tandem-Okklusionen im akuten Schlaganfall: Antegrader Zugang und Behandlung mittels Wallstent und Solitaire stent-retriever



Akute Gefäßverschlüsse der großen hirnversorgenden Arterien haben niedrige Rekanalisierungsraten unter alleiniger systemischer Thrombolyse mit rTPA. Die Effizienz einer stent-retriever basierten, mechanischen Thrombektomie in Patienten mit einem zusätzlichen extrakraniellen Verschluss der A. carotis interna, die zunächst extrakraniell gestentet werden müssen, um einen intrakraniellen Zugang zu ermöglichen, ist wenig untersucht. In der vorliegenden Arbeit wurde das klinische Outcome nach endovaskulärer Rekanalisation im akuten Schlaganfall bei Tandem-Okklusionen der vorderen Zirkulation untersucht.


Basierend auf spezifischen Ein- und Ausschluss-Kriterien wurden geeignete Patienten mit Verschlüssen großer hirnversorgender Arterien mittels mechanischer Thrombektomie mit dem Solitaire stent-retriever behandelt. Im Falle einer Tandem-Okklusion wurde eine akute Stentimplantation (Wallstent) vorgeschaltet. Zwischen Oktober 2009 und März 2011 wurden 50 Patienten endovaskulär behandelt. Erfasst wurde neben den klinischen und angiographischen Parametern auch das klinische Outcome nach 90 Tagen.


41 Patienten hatten einen Verschluss eines großen hirnversorgenden Gefässes in der vorderen, 9 in der hinteren Zirkulation. Die Rekanalisationsrate betrug in der vorderen Zirkulation 85 % (35/41). 6/41 Patienten (15 %) verstarben in der akuten Phase. In 17/41 Patienten (42 %) war eine vorgeschaltete, akute, Stent-basierte Rekanalisation der extrakraniellen A. carotis interna erforderlich. Die respektiven NIHSS (National Institutes of Stroke Health Scale) und mRS (modifizierte Rankin Skala) Scores verbesserten sich sowohl in der Gruppe der akut gestenteten Patienten, als auch in der Gruppe der nicht gestenteten Patienten; es wurden keine signifikanten Unterschiede zwischen beiden Gruppen beobachtet. Nach 90 Tagen wiesen 54 % der akut gestenteten Patienten ein gutes klinisches Ergebniss auf.


Die Kombination eines akuten extrakraniellen Stentings der A. carotis interna verbunden mit einer anschließenden intrakraniellen mechanischen Rekanalisation mittels Solitaire ist technisch sicher und kann zu einer Verbesserung des neurologischen Ergebnisses bei Patienten führen, die unter alleiniger systemischer Thrombolyse eine eingeschränkte Prognose aufweisen


Schlaganfall Thrombektomie Thrombolyse rTPA Akutes Stenting Solitaire Tandem-Okklusion 



AM and MB contributed equally to the manuscript. No other persons apart from the authors have made substantial contributions to this manuscript.


  1. 1.
    Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007;38(3):967–73.PubMedCrossRefGoogle Scholar
  2. 2.
    Saqqur M, Uchino K, Demchuk AM, Molina CA, Garami Z, Calleja S, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke. 2007;38(3):948–54.PubMedCrossRefGoogle Scholar
  3. 3.
    Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012;380(9849):1240–9.Google Scholar
  4. 4.
    Pancioli AM, Broderick J, Brott T, Tomsick T, Khoury J, Bean J, et al. The combined approach to lysis utilizing eptifibatide and rt-PA in acute ischemic stroke: the CLEAR stroke trial. Stroke. 2008;39(12):3268–76.PubMedCrossRefGoogle Scholar
  5. 5.
    Castano C, Dorado L, Guerrero C, Millan M, Gomis M, Perez de la Ossa N, et al. Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke. 2010;41(8):1836–40.PubMedCrossRefGoogle Scholar
  6. 6.
    Miteff F, Faulder KC, Goh AC, Steinfort BS, Sue C, Harrington TJ. Mechanical thrombectomy with a self-expanding retrievable intracranial stent (Solitaire AB): experience in 26 patients with acute cerebral artery occlusion. Am J Neuroradiol. 2011;32(6):1078–81.PubMedCrossRefGoogle Scholar
  7. 7.
    Mpotsaris A, Bussmeyer M, Loehr C, Oelerich M, Buchner H, Weber W. Mechanical thrombectomy in severe acute stroke: preliminary results of the Solitaire stent. J Neurol Neurosurg Psychiatry. 2012;83(1):117–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Nayak S, Ladurner G, Killer M. Treatment of acute middle cerebral artery occlusion with a Solitaire AB stent: preliminary experience. Br J Radiol. 2010;83(996):1017–22.PubMedCrossRefGoogle Scholar
  9. 9.
    Park H, Hwang GJ, Jin SC, Jung CK, Bang JS, Han MK, et al. A retrieval thrombectomy technique with the Solitaire stent in a large cerebral artery occlusion. Acta Neurochir (Wien). 2011;153(8):1625–31.PubMedCrossRefGoogle Scholar
  10. 10.
    Stampfl S, Hartmann M, Ringleb PA, Haehnel S, Bendszus M, Rohde S. Stent placement for flow restoration in acute ischemic stroke: a single-center experience with the Solitaire stent system. Am J Neuroradiol. 2011;32(7):1245–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Koh JS, Lee SJ, Ryu CW, Kim HS. Safety and efficacy of mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke: a systematic review. Neurointervention. 2012;7(1):1–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Costalat V, Machi P, Lobotesis K, Maldonado I, Vendrell JF, Riquelme C, et al. Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study: timing, safety, and efficacy. Stroke. 2011;42(7):1929–35.PubMedCrossRefGoogle Scholar
  13. 13.
    Machi P, Costalat V, Lobotesis K, Maldonado IL, Vendrell JF, Riquelme C, et al. Solitaire FR thrombectomy system: immediate results in 56 consecutive acute ischemic stroke patients. J Neurointerv Surg. 2012;4(1):62–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Dorn F, Stehle S, Lockau H, Zimmer C, Liebig T. Endovascular treatment of acute intracerebral artery occlusions with the solitaire stent: single-centre experience with 108 recanalization procedures. Cerebrovasc Dis. 2012;34(1):70–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Davalos A, Pereira VM, Chapot R, Bonafe A, Andersson T, Gralla J. Retrospective multicenter study of Solitaire FR for revascularization in the treatment of acute ischemic stroke. Stroke. 2012;43(10)2699–705.PubMedCrossRefGoogle Scholar
  16. 16.
    Dabitz R, Triebe S, Leppmeier U, Ochs G, Vorwerk D. Percutaneous recanalization of acute internal carotid artery occlusions in patients with severe stroke. Cardiovasc Intervent Radiol. 2007;30(1):34–41.PubMedCrossRefGoogle Scholar
  17. 17.
    Du Mesnil De Rochemont R, Sitzer M, Neumann-Haefelin T, Harmjanz A, Berkefeld J. Endovascular recanalization of acute atherothrombotic carotid artery occlusion holds up progressive stroke. Neuroradiology. 2004;46(7):583–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Imai K, Mori T, Izumoto H, Watanabe M, Majima K. Emergency carotid artery stent placement in patients with acute ischemic stroke. Am J Neuroradiol. 2005;26(5):1249–58.PubMedGoogle Scholar
  19. 19.
    Jovin TG, Gupta R, Uchino K, Jungreis CA, Wechsler LR, Hammer MD, et al. Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke. 2005;36(11):2426–30.PubMedCrossRefGoogle Scholar
  20. 20.
    Nedeltchev K, Brekenfeld C, Remonda L, Ozdoba C, Do DD, Arnold M, et al. Internal carotid artery stent implantation in 25 patients with acute stroke: preliminary results. Radiology. 2005;237(3):1029–37.PubMedCrossRefGoogle Scholar
  21. 21.
    Malik AM, Vora NA, Lin R, Zaidi SF, Aleu A, Jankowitz BT, et al. Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience. Stroke. 2011;42(6):1653–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Hauck EF, Natarajan SK, Ohta H, Ogilvy CS, Hopkins LN, Siddiqui AH, et al. Emergent endovascular recanalization for cervical internal carotid artery occlusion in patients presenting with acute stroke. Neurosurgery. 2011;69(4):899–907; discussion 907.PubMedCrossRefGoogle Scholar
  23. 23.
    Cohen JE, Gomori M, Rajz G, Moscovici S, Leker RR, Rosenberg S, et al. Emergent stent-assisted angioplasty of extracranial internal carotid artery and intracranial stent-based thrombectomy in acute tandem occlusive disease: technical considerations. J Neurointerv Surg. 2012 (in press).Google Scholar
  24. 24.
    Adams HP Jr, Bendixen BH, Leira E, Chang KC, Davis PH, Woolson RF, et al. Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999;53(1):122–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Rubiera M, Ribo M, Delgado-Mederos R, Santamarina E, Delgado P, Montaner J, et al. Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke. 2006;37(9):2301–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Akbari SH, Reynolds MR, Kadkhodayan Y, Cross DT 3rd, Moran CJ. Hemorrhagic complications after prasugrel (Effient) therapy for vascular neurointerventional procedures. J Neurointerv Surg. 2012 (in press).Google Scholar
  27. 27.
    Stetler WR, Chaudhary N, Thompson BG, Gemmete JJ, Maher CO, Pandey AS. Prasugrel is effective and safe for neurointerventional procedures. J Neurointerv Surg. 2012 (in press).Google Scholar
  28. 28.
    Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363(9411):768–74.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • A. Mpotsaris
    • 1
  • M. Bussmeyer
    • 2
  • H. Buchner
    • 2
  • W. Weber
    • 1
  1. 1.Klinik für Radiologie, Neuroradiologie und interventionelle TherapieKlinikum Vest, KnappschaftskrankenhausRecklinghausenGermany
  2. 2.Klinik für Neurologie und Klinische NeurophysiologieKlinikum Vest, KnappschaftskrankenhausRecklinghausenGermany

Personalised recommendations