Article

Another Endovascular Therapy Strategy for Acute Tandem Occlusion: Protect-Expand-Aspiration-Revascularization-Stent (PEARS) Technique

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Abstract

Purpose: Initial stenotic occlusion of the internal carotid artery (ICA) with intracranial artery occlusion in acute ischemic stroke is associated with high morbidity and can benefit from endovascular therapy. However, the optimal endovascular strategy is unclear. This study aimed to evaluate the feasibility of the "half" anterograde approach and clinical outcome of treated patients. Revascularization validity of the two "half" anterograde approach with (PEARS technique) or without (plain technique) using an embolic prevention device and aspiration was also compared. Materials and methods: Data on initial stenotic occlusion of the ICA with intracranial artery occlusion in our prospective stroke registry database between January 2015 and February 2017 were collected. Clinical and angiographic data were retrospectively analyzed. Clinical outcome was evaluated at 3 months (mRS), defined as an mRS ≤2 as a good clinical outcome. Results: Overall, 26 patients with tandem occlusion were included, 96.3% of patients had successful recanalization. The rate of a good clinical outcome was 61.8%, symptomatic parenchymal hemorrhage was 7.7%, and mortality was 15.4%. The PEARS technique took less time (56±14 versus 97±31 min, P=0.002) and had less embolic events (0% versus 30.8%, P=0.012) compared with the plain technique. Use of the PEARS technique was an independent predictor for shortening revascularization time (β =-0.651, P=0.001). Conclusion: The half anterograde approach technique is feasible and safe for treating tandem occlusion. Furthermore, the PEARS technique is associated with a shorter reperfusion time and less embolic events than the plain technique, and should be recommended in tandem occlusion.

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... The average time from groin puncture to recanalization in our series was 71.2 min, better than 81 min in a report by Rangel-Castilla et al. [8] We also achieved 82.4% of good recanalization in total 35.3% of TICI-3 (complete recanalization). This result, particularly, was higher than one published by Yang et al. [4,7,8,12] It resulted in our 52.9% early clinical improvement (NIHSS reduced ≥4 or to 0 or 1 in the next day) and 47.1% favorable outcome (MRS ≤2) after 3 months, which was equivalent to records by Mpotsaris [4,7,8,[11][12][13] In contrast, our series did not identify any patients who died after 3 months while death rate was 32%, 20%, 15.4%, and 13% in other the reports published by Sallustio et al., Grigoryan et al., Yi et al., and Mpotsaris et al., respectively. ...
... This result, particularly, was higher than one published by Yang et al. [4,7,8,12] It resulted in our 52.9% early clinical improvement (NIHSS reduced ≥4 or to 0 or 1 in the next day) and 47.1% favorable outcome (MRS ≤2) after 3 months, which was equivalent to records by Mpotsaris [4,7,8,[11][12][13] In contrast, our series did not identify any patients who died after 3 months while death rate was 32%, 20%, 15.4%, and 13% in other the reports published by Sallustio et al., Grigoryan et al., Yi et al., and Mpotsaris et al., respectively. [4,7,11,13] Symptomatic hemorrhage within 24-h procedure was seen in two cases (11.8%), which was higher than the other reports done by Steglich-Arnholm et al. (4%) and Mpotsaris et al. (5%) but lower than a work done by Sallustio et al. (12.5%). ...
... early clinical improvement (NIHSS reduced ≥4 or to 0 or 1 in the next day) and 47.1% favorable outcome (MRS ≤2) after 3 months, which was equivalent to records by Mpotsaris [4,7,8,[11][12][13] In contrast, our series did not identify any patients who died after 3 months while death rate was 32%, 20%, 15.4%, and 13% in other the reports published by Sallustio et al., Grigoryan et al., Yi et al., and Mpotsaris et al., respectively. [4,7,11,13] Symptomatic hemorrhage within 24-h procedure was seen in two cases (11.8%), which was higher than the other reports done by Steglich-Arnholm et al. (4%) and Mpotsaris et al. (5%) but lower than a work done by Sallustio et al. (12.5%). [11,13,14] A PH-2 hemorrhagic patient with severely mass effect from Group 1 underwent a surgery of cerebral hematomectomy and his MRS was 5 after 3 months. ...
Article
Background and purpose: Tandem occlusive lesion, a major challenge for thrombectomy in acute anterior circulation strokes, is poorly represented in randomized trials. This study demonstrates the findings of thrombectomy in tandem occlusion and comparative analysis of two treatment groups (extracranial versus intracranial first subgroup). Patients and methods: We enrolled and divided 17 patients with acute tandem ischemic stroke who received endovascular treatment into two groups. Group 1 with completed (100%) internal carotid artery (ICA) occlusion was treated by an extracranial stent, whereas Group 2 with severe (70%-99%) ICA occlusion was prioritized with intracranial thrombectomy. Data of clinical parameters, imaging and angiographic results, periprocedural complications, and results after 3 months were collected and analyzed. Results: The mean age of patients was 70.2 ± 8.8 years, and males accounted for 94.1%. The National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score (ASPECTS) baseline were 16.6 ± 4.2 and 7.6 ± 1.1, respectively, with occlusive side was 52.9% on the right. Group 1 including ten cases (58.8%) was treated extracranial lesion with carotid stent before intracranial thrombectomy, and Group 2 with seven cases (41.2%) was prioritized intracranial thrombectomy. In total 17 procedures, there were ten stent retrievers (58.8%), four aspirations (23.5%), and three Solumbra (17.7%). No re-occlusion of carotid stent postoperation was recorded. The good revascularization (thrombolysis in cerebral infarction 2b-3) was archived in 82.4% of patients, while symptomatic hemorrhage was seen in 2 cases (11.8%). Three months after treatment, patients with favorable clinical outcome (Modified Rankin Scale ≤2) accounted for 47.1%. Conclusion: Our study determined a promising outcome with reasonable good recanalization and clinical recovery for endovascular intervention in tandem ischemic. In the subgroup of treatment, "extracranial stent first" had more complex disease with completed ICA occlusion which required longer procedure time may lead to worse outcome.
... Both of these methods have limitations, and new techniques have been proposed. [10,11] There is controversy regarding whether carotid stenting should be performed in conjunction with EVT. Without proper premedication, the rate of reocclusion is high, [12,13] and the risk of hemorrhage should be balanced with the risk of rethrombosis. ...
... [18] Yi et al. described the deployment of DPDs through a microcatheter during the first cross of extracranial lesions and performing aspirations. [11] However, the vascular anatomy might not be clear with an angiographic run through the microcatheter, and the DPD should be deployed with caution. Thrombus might be present along the cervical ICA, which cannot be reached by a DPD. ...
Article
Background: Endovascular thrombectomy (EVT) for acute ischemic stroke associated with tandem lesion is challenging. Achieving rapid intracranial revascularization and managing the extracranial lesion without complications are the main challenges. Materials and Methods: The balloon angioplasty followed by aspiration of large-vessel occlusion (BAFALO) technique was used to address this clinical issue. A review of a prospectively maintained stroke registry from January 2015 to April 2020 was performed. Patients had stroke with TO and treated with the BAFALO technique were included. Results: Twelve patients were enrolled: 11 had anterior circulation stroke, and 1 had posterior circulation stroke. There were 10 ipsilateral internal carotid artery stenosis/occlusion, one left common carotid artery to subclavian artery bypass stenosis, and 1 vertebral artery orifice stenosis. The median National Institutes of Health Stroke Scale score was 16 (interquartile range [IQR]: 14–16). Revascularization with a Modified Thrombolysis in Cerebral Infarction score of 2b or more was achieved in 11 (92%) patients. The median puncture-to-revascularization time was 25 min (IQR: 19.5–31). Emergent stent implantation was performed in five (42%) patients. Three had distal protection devices (DPDs) with no distal embolization. Two patients did not use a DPD, and one had intracranial reocclusion. Eight (67%) proximal stenotic vessels remained patent. No symptomatic intracranial hemorrhage occurred. Eight (67%) patients had favorable clinical outcomes (modified Rankin Score 0–2 at 90 days). Conclusion: While managing TO, the BAFALO technique could achieve rapid intracranial revascularization and treat extracranial lesions under embolic protection. These merits translate into favorable clinical outcomes.
... Кардіогенна емболія часто призводить до більшої оклюзії прецеребральних і церебральних артерій. Ендоваскулярні методи реперфузії із застосуванням сучасних стент-ретриверів та дистальних аспіраційних катетерів є єдиним ефективним варіантом відновлення церебрального кровотоку при тандемному розташуванні тромбів, що дає сприятливі клінічні результати [10,11]. Показана ефективність цих методів при гострому ішемічному інсульті внаслідок оклюзії великих артерій, але немає єдиної думки щодо тактики ендоваскулярного лікування у разі тандемних оклюзій. ...
... Показана ефективність цих методів при гострому ішемічному інсульті внаслідок оклюзії великих артерій, але немає єдиної думки щодо тактики ендоваскулярного лікування у разі тандемних оклюзій. Останні мало представлені в клінічних дослідженнях, присвячених тромбектомії при інсульті [11]. Лише невелику кількість пацієнтів з тандемними оклюзіями залучено до рандомізованих досліджень, що оцінюють механічну тромбектомію. ...
Article
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Objective – to evaluate the efficacy and safety of endovascular treatment in patients with acute ischemic stroke due to tandem occlusions.Materials and methods. The results of the examination and treatment of 237 patients with acute ischemic stroke due to large vessel occlusion who underwent endovascular reperfusion were analyzed. Tandem occlusions (internal carotid ‒ middle cerebral artery) were diagnosed in 65 (27.4 %) cases. Patient age ranged from 29 to 84 years (mean age ‒ 64.8 years). Men predominated among the patients (46 (70.8 %)). Among patients with ischemic stroke due to tandem occlusion, 29 (44.6 %) were diagnosed with atherothrombotic stroke subtype, 27 (41.5 %) had cardioembolic. In 9 (13.9 %) cases the cause of thrombosis was spontaneous dissection of the wall of the internal carotid artery. To assess collateral blood flow, the ACG scale proposed by the American Society for Interventional and Therapeutic Radiology was used. The quality of reperfusion was assessed using the eTICI scale. Analysis of the functional results of patients after 90 days from the onset of the disease was carried out according to the modified Rankine scale (mSR).Results. According to our study, a good angiographic result (eTICI 2b-3) was achieved in 54 (83.1 %) patients. Intraoperative complications were registered in 8 (12.3 %) cases. An analysis of the dependence of the quality of reperfusion on the severity of collateral compensation of a thrombosed artery showed that in patients with developed (ACG 3-4) collaterals (35 (53.8 %)) good reperfusion was achieved in 33 (94.3 %) cases, in patients with mild (ACG 0-2) collateral compensation (30 (46.2 %)) the quality of eTICI 2b-3 reperfusion was achieved only in 21 (70.0 %) cases. It was found that out of 40 (61.5 %) patients with tandem occlusion, in whom arterial puncture was performed within 6 hours after the onset of neurological symptoms, 15 (37.5 %) had 0-2 points for mSR after 90 days. When puncturing the artery later than 6 hours (25 (38.5 %) cases), a good result after 90 days was registered only in 7 (28.0 %) patients. Analysis of the influence of collaterals on the dynamics of changes according to multislice computed tomography revealed that patients with well-defined collaterals (35 (53.8 %) cases) during the control examination had ASPECTS scores from 1 to 9 points (average ‒ 5.3 points). Patients with mild collaterals (30 (46.2 %) observations)) on the ASPECTS scale during the control examination had from 0 to 6 points (average ‒ 2.2 points). During the first day or at the time of discharge, a statistically significant decrease in neurological deficit was observed in the group with successful restoration of cerebral blood flow findings.Conclusions. Many factors influence the clinical efficacy of endovascular reperfusion techniques: hypoperfusion area and area of brain damage according to computed tomography during hospitalization, quality of endovascular reperfusion, time from the onset of the disease, collateral compensation of the thrombosed artery basin, complications during surgery. Well-defined collaterals are a predictor of positive dynamics after successful endovascular reperfusion.
Objectives This study aims to evaluate whether the presence of an external carotid artery embolism accompanying internal carotid artery occlusion may contribute to identifying the etiology of internal carotid artery occlusion in the early period. Material and methods The presence of external carotid artery embolism was evaluated in 117 patients who were adjudicated for internal carotid artery occlusion based on digital subtraction angiography images. Results Embolus in the external carotid artery was detected in 8 (6.8%) of the 117 patients with internal carotid artery occlusion (7 (87.5%) patients were found to have tandem and 1 (12.5%) patient had carotid T occlusion). In all of these patients, the thrombus was of embolic origin. Evaluation of the etiology revealed cardioembolic etiology in 4 patients and dissection in 1 patient, and the cause could not be determined in the remaining 3 patients. Patients with external carotid artery embolism accompanying an internal carotid artery occlusion had significantly higher The National Institutes of Health Stroke Scale scores at admission and significantly lower recanalization success compared to those without external carotid artery embolism (p = 0.009, p = 0.01). In the comparison of prognosis, poorer prognosis was observed in those with external carotid artery embolism, although without a statistically significant difference (p = 0.07). Conclusions This study observed that the etiology was mostly embolic in patients with external carotid artery embolism accompanying an internal carotid artery occlusion, most of whom were found to have tandem embolic occlusion, and cardiac origin appeared to be the prominent etiology of stroke.
Article
Background: and Purpose: Acute intracranial atherosclerotic disease (IAD)-related large artery occlusion (LAO) is typically refractory to mechanical thrombectomy. We evaluated the feasibility and safety of emergency balloon-assisted or stent-assisted angioplasty performed with tirofiban administration for acute IAD-related LAO. Methods: We identified, from among 55 consecutive patients who underwent endovascular treatment for LAO, 12 patients with acute IAD-related LAO who underwent balloon-assisted or stent-assisted angioplasty with (n = 3) or without passage of a stent retriever. The treatment included tirofiban administration. We obtained, from patients' clinical records, TICI scores (to assess the extent of reperfusion), follow-up magnetic resonance angiography images (to assess patency of the responsive arteries), and 90-day modified Rankin (mRS) scores (to assess outcomes). Results: Temporary blood flow and severe stenosis were observed angiographically in all 12 patients, either when the stent retriever was deployed or when a microcatheter was advanced through the site of occlusion. Persistent recanalization was achieved in all patients, and there was no operative complication or arterial re-occlusion. All 8 patients with an occluded major artery in the anterior circulation had a good outcome, with an mRS score of ≤2. Two of the 4 patients with basilar artery occlusion had a good outcome, with an mRS score of ≤2. One patient (25%) died within 72 hours after procedure. Conclusions: Our data point to the safety and feasibility of emergency balloon- or stent-assisted angioplasty performed with tirofiban administration and a single or no passage of the stent retriever for acute IAD-related LAO.
Article
Background Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre. Methods This was a retrospective analysis of all consecutive patients with acute extracranial carotid artery occlusion including acute dissection or high-grade stenosis and concomitant intracranial large-vessel occlusion treated with emergency carotid stenting and intracranial mechanical thrombectomy between November 2007 and May 2015. Results A total of 63 patients with a median age of 67 years (range 33–84 years) were treated. Of these, 33 (52%) patients had concomitant intravenous thrombolysis with recombinant tissue-type plasminogen activator initially. Median admission National Institutes of Health Stroke Scale was 14 (range 1–29). Median time from stroke onset to recanalization was 408 minutes (range 165–1846 minutes). Procedure time was significantly shorter after intravenous thrombolysis (110 minutes [range 15–202 minutes] vs. 130 minutes [range 60–280 minutes]; p = 0.02). Three (5%) patients experienced post-procedural symptomatic intracerebral haemorrhage. In 55/63 (87%) patients, a score of ≥2b on the Thrombolysis in Cerebral Infarction scale could be achieved. Eight (13%) patients died, five (8%) during the acute phase. A total of 29/63 (46%) patients showed a favourable outcome (modified Rankin Scale score of 0–2) after three months. Conclusions Our single-centre retrospective analysis of emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy demonstrated high technical success, reasonable clinical outcomes and acceptable rates of symptomatic intracranial haemorrhage in carefully chosen patients which are triaged interdisciplinary based on clinical and computed tomography imaging criteria. This warrants further study in a randomised prospective trial.
Article
Objectives To assess the efficacy and safety profile of stent-retriever thrombectomy (SRT) in acute anterior ischemic stroke patients with tandem occlusion. Materials and methodsUsing the MEDLINE database, we conducted a systematic review and meta-analysis of all studies that included patients with acute ischemic stroke attributable to tandem occlusion who received treatment with SRT between November 2010 and May 2015. ResultsThe literature search identified 11 previous studies involving a total of 237 subjects out of whom 193 (81.4 %) were treated with acute stent placement for the extracranial internal carotid artery occlusion. Mean initial NIHSS score was 17, and median time from onset to recanalization was 283.5 min. Mean intravenous thrombolysis rate was 63.8 %. In the meta-analysis, the recanalization rate reached 81 % (95 % CI, 73–89). Meta-analysis of clinical outcomes showed a pooled estimate of 44 % (95 % CI, 33–55; 10 studies) for favourable outcome, 13 % (95 % CI, 8–20; 10 studies) for mortality, and 7 % (95 % CI, 2–13; eight studies) for symptomatic intracranial haemorrhage. ConclusionSRT with emergency carotid stenting is associated with acceptable safety and efficacy in acute anterior stroke patients with tandem occlusion compared to natural history. However, the best modality to treat proximal stenosis is based on an individual case basis. Key Points• Stent retriever thrombectomy of tandem occlusion is efficient and safe.• Emergent carotid stenting during thrombectomy increase symptomatic intracranial haemorrhage without impact mortality.• Thrombectomy of tandem anterior circulation occlusion may be the first therapeutic option
Article
Background: In 2015, five randomised trials showed efficacy of endovascular thrombectomy over standard medical care in patients with acute ischaemic stroke caused by occlusion of arteries of the proximal anterior circulation. In this meta-analysis we, the trial investigators, aimed to pool individual patient data from these trials to address remaining questions about whether the therapy is efficacious across the diverse populations included. Methods: We formed the HERMES collaboration to pool patient-level data from five trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA) done between December, 2010, and December, 2014. In these trials, patients with acute ischaemic stroke caused by occlusion of the proximal anterior artery circulation were randomly assigned to receive either endovascular thrombectomy within 12 h of symptom onset or standard care (control), with a primary outcome of reduced disability on the modified Rankin Scale (mRS) at 90 days. By direct access to the study databases, we extracted individual patient data that we used to assess the primary outcome of reduced disability on mRS at 90 days in the pooled population and examine heterogeneity of this treatment effect across prespecified subgroups. To account for between-trial variance we used mixed-effects modelling with random effects for parameters of interest. We then used mixed-effects ordinal logistic regression models to calculate common odds ratios (cOR) for the primary outcome in the whole population (shift analysis) and in subgroups after adjustment for age, sex, baseline stroke severity (National Institutes of Health Stroke Scale score), site of occlusion (internal carotid artery vs M1 segment of middle cerebral artery vs M2 segment of middle cerebral artery), intravenous alteplase (yes vs no), baseline Alberta Stroke Program Early CT score, and time from stroke onset to randomisation. Findings: We analysed individual data for 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to control). Endovascular thrombectomy led to significantly reduced disability at 90 days compared with control (adjusted cOR 2·49, 95% CI 1·76-3·53; p<0·0001). The number needed to treat with endovascular thrombectomy to reduce disability by at least one level on mRS for one patient was 2·6. Subgroup analysis of the primary endpoint showed no heterogeneity of treatment effect across prespecified subgroups for reduced disability (pinteraction=0·43). Effect sizes favouring endovascular thrombectomy over control were present in several strata of special interest, including in patients aged 80 years or older (cOR 3·68, 95% CI 1·95-6·92), those randomised more than 300 min after symptom onset (1·76, 1·05-2·97), and those not eligible for intravenous alteplase (2·43, 1·30-4·55). Mortality at 90 days and risk of parenchymal haematoma and symptomatic intracranial haemorrhage did not differ between populations. Interpretation: Endovascular thrombectomy is of benefit to most patients with acute ischaemic stroke caused by occlusion of the proximal anterior circulation, irrespective of patient characteristics or geographical location. These findings will have global implications on structuring systems of care to provide timely treatment to patients with acute ischaemic stroke due to large vessel occlusion. Funding: Medtronic.
Article
Acute tandem occlusions of the cervical and distal internal carotid artery (ICA) or middle cerebral artery (MCA) are associated with major stroke with intravenous (i.v.) thrombolysis alone in approximately 90 % of patients. The data on endovascular management of tandem occlusions is still limited. The purpose of this study was to review technical aspects and the current state of the literature on acute ICA stenting in combination with stent retriever-based intracranial thrombectomy. We retrospectively reviewed the data of 37 consecutive patients with tandem occlusions including clinical parameters, angiographic results, procedural aspects, complications, and hemorrhages. Median National Institutes of Health Stroke Scale (NIHSS) on admission was 17 (3-30). Intracranial thrombectomy was performed prior to ICA stenting in 25/37 (67.6 %) and after stenting in 12/37 (32.4 %) patients. ICA stenting was successful in all cases, and a thrombolysis in cerebral infarction (TICI) scale 2b/3 result was achieved in 27/37 (73 %) cases. The mean angiography time was significantly shorter in the "thrombectomy first" group (43.1 ± 30.8 vs. 110.8 ± 43.0 min, p < 0.001), and more patients had favorable outcomes after 3 months (13/25 = 52.0 vs. 4/12 = 33.3 %, p = 0.319). In this group, intermediate catheters were used and successfully prevented embolism to unaffected territories in all cases. Acute stenting of the cervical ICA in combination with intracranial thrombectomy was technically feasible and safe in our series. Thrombectomy prior to proximal stenting was associated with shorter reperfusion times and a tendency towards better clinical outcome leading to a good outcome in about 50 % of the patients. Therefore, we recommend this approach in tandem occlusion requiring stent angioplasty.
Article
Purpose: 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. Methods: 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. Results: 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. Conclusion: 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.
Article
Background: 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. Methods: 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. Results: 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. Conclusions: 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.
Article
The optimal treatment in the acute phase of cervical internal carotid occlusion associated with intracranial obstruction is a matter of debate. In this study, we report our experience using the Solitaire FR revascularization device and synchronous intravenous fibrinolysis. The distal occlusion was treated with Solitaire FR before the proximal one in all cases, a technique not reported so far in the literature. We examined all cases of tandem occlusion treated in our institution between November 2009 and November 2010. The proximal occlusion was treated using manual thromboaspiration in order to achieve intracranial recanalization as rapid as possible. When necessary, stenting was performed after the reconstitution of the intracranial vessel. Morphological and clinical results were recorded in the immediate post-operative phase and at the three-month follow-up. Clinical success was defined as a mRS at 3 months ≤2. Four male and six female patients were treated (mean age 66 years). The cervical carotid was recanalized in all cases and the intracranial vessel (TICI≥2b) in eight. Adverse events were recorded in four patients of which three were asymptomatic. These included two cases of subarachnoid hemorrhage, one case of traumatic dissection, and one case of fatal intra-cerebral hemorrhage seven days following the procedure. At the three-month follow-up a mRS≤2 was observed in four patients. The described approach for the treatment of tandem occlusions is promising with regard to both morphological and clinical assessments and thus may be considered a valid tool in acute stroke.