Two in One: Endovascular Treatment of Acute Tandem Occlusions in the Anterior Circulation
- 657 Downloads
Acute major stroke with high-grade stenosis or occlusion of the extracranial internal carotid artery (ICA) and additional intracranial large artery occlusion is increasingly treated with a mechanical endovascular approach by extracranial stenting and intracranial thrombectomy due to poor response to systemic thrombolysis with recombinant tissue plasminogen activator (rtPA). This article presents a single centre cohort of this challenging subtype of stroke, describing the technical procedure and analysing the angiographic and clinical outcome.
Clinical and imaging data of all consecutive patients between July 2008 and March 2013 with intracranial artery occlusion in the anterior circulation and additional occlusion or pseudo-occlusion of the cervical ICA were retrospectively analysed with respect to demographical and clinical characteristics. Technical approach, recanalization rate, recanalization time and short-term clinical outcome were determined.
A total of 43 patients with tandem occlusion in the anterior circulation met the inclusion criteria. Out of these, 32 (74.4 %) occlusions and 11 (25.6 %) pseudo-occlusions of the extracranial ICA with additional occlusion of the distal segment of the ICA in 7.0 % (3/43), the M1-segment of the middle cerebral artery (MCA) in 81.4 % (35/43) or the M2-segment of the MCA in 11.6 % (5/43) of cases were treated with combined endovascular approach including extracranial stenting with angioplasty and intracranial mechanical thrombectomy. In 76.7 % of cases, an angiographic recanalization result of 2b or 3 using the Thrombolysis in Cerebral Infarction (TICI) score was achieved. Mean time from first angiographic series to recanalization was 103 min. A modified Rankin Scale (mRS) score of ≤ 2 was achieved in 32.6 % at the time of discharge.
Endovascular therapy of patients with tandem occlusion in the anterior circulation with emergency extracranial stenting and intracranial mechanical thrombectomy appears to be safe and may lead to a satisfactory angiographic result and clinical outcome.
KeywordsStroke Thrombectomy Stent Tandem occlusion
Conflict of Interest
C. Maurer received an educational grant from Boston Scientific and Stryker.
A. Berlis has consultancy agreements with Boston Scientific, Stryker and ev3/Covidien
- 5.Fischer U, Mono M, Schroth G, Jung S, Mordasini P, El-Koussy M, Weck A, Brekenfeld C, Findling O, Galimanis A, Heldner MR, Arnold M, Mattle HP, Gralla J. Endovascular therapy in 201 patients with acute symptomatic occlusion of the internal carotid artery. Eur J Neurol. 2013;20:1017–24, e87.CrossRefPubMedGoogle Scholar
- 8.Puri AS, Kühn AL, Kwon H, Khan M, Hou SY, Lin E, Chueh J, van der Bom, Imramsjah Mj, Dabus G, Linfante I, Gounis MJ, Wakhloo AK. Endovascular treatment of tandem vascular occlusions in acute ischemic stroke. J Neurointerv Surg. 2014 Feb 27. doi: 10.1136/neurintsurg-2013-011010. [Epub ahead of print].Google Scholar
- 9.Spiotta AM, Lena J, Vargas J, Hawk H, Turner RD, Chaudry MI, Turk AS. Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke. J Neurointerv Surg. 2014 Feb 21. doi: 10.1136/neurintsurg-2013-011040. [Epub ahead of print].Google Scholar
- 10.Cohen JE, Gomori M, Rajz G, Moscovici S, Leker RR, Rosenberg S, Itshayek E. Emergent stent-assisted angioplasty of extracranial internal carotid artery and intracranial stent-based thrombectomy in acute tandem occlusive disease: technical considerations. J Neurointerv Surg. 2013;5:440–6.CrossRefPubMedGoogle Scholar
- 11.Lekoubou A, Cho T, Nighoghossian N, Kumako V, Derex L, Trouillas P, Turjman F. Combined intravenous recombinant-tissular plasminogen activator and endovascular treatment of spontaneous occlusive internal carotid dissection with tandem intracranial artery occlusion. Eur. Neurol. 2010;63:211–4.CrossRefPubMedGoogle Scholar
- 12.Malik AM, Vora NA, Lin R, Zaidi SF, Aleu A, Jankowitz BT, Jumaa MA, Reddy VK, Hammer MD, Wechsler LR, Horowitz MB, Jovin TG. Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience. Stroke. 2011;42:1653–7.CrossRefPubMedGoogle Scholar
- 16.Lewandowski CA, Frankel M, Tomsick TA, Broderick J, Frey J, Clark W, Starkman S, Grotta J, Spilker J, Khoury J, Brott T. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial. Stroke. 1999;30:2598–605.CrossRefPubMedGoogle Scholar
- 18.De Silva, Deidre A, Brekenfeld C, Ebinger M, Christensen S, Barber PA, Butcher KS, Levi CR, Parsons MW, Bladin CF, Donnan GA, Davis SM. The benefits of intravenous thrombolysis relate to the site of baseline arterial occlusion in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET). Stroke. 2010;41:295–9.CrossRefGoogle Scholar
- 20.Behme D, Gondecki L, Fiethen S, Kowoll A, Mpotsaris A, Weber W. Complications of mechanical thrombectomy for acute ischemic stroke-a retrospective single-center study of 176 consecutive cases. Neuroradiology. 2014;56:467–76.Google Scholar
- 22.Kwak HS, Hwang SB, Jin GY, Hippe DS, Chung GH. Predictors of functional outcome after emergency carotid artery stenting and intra-arterial thrombolysis for treatment of acute stroke associated with obstruction of the proximal internal carotid artery and tandem downstream occlusion. AJNR Am J Neuroradiol. 2013;34:841–6.CrossRefPubMedGoogle Scholar
- 25.Langner S, Khaw AV, Fretwurst T, Angermaier A, Hosten N, Kirsch M. Endovaskuläre Therapie des akut ischämischen Schlaganfalls unter Analgosedierung im Vergleich zur Intubationsnarkose – Durchführbarkeit, periprozedurale Sicherheit, klinisches und radiologisches Outcome. Rofo. 2013;185:320–7.CrossRefPubMedGoogle Scholar