title: Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience.
abstract: OBJECTIVE
  Acute ischemic stroke due to tandem occlusions of the extracranial internal carotid artery and intracranial arteries has a poor natural history. We aimed to evaluate our single-center experience with endovascular treatment of this unique stroke population.
  
  
  METHODS
  Consecutive patients with tandem occlusions of the internal carotid artery origin and an intracranial artery (ie, internal carotid artery terminus, M1 middle cerebral artery, or M2 middle cerebral artery) were studied retrospectively. Treatment consisted of proximal revascularization with angioplasty and stenting followed by intracranial intervention. Endpoints were recanalization of both extracranial and intracranial vessels (Thrombolysis In Myocardial Ischemia ≥2), parenchymal hematoma, and good clinical outcome (modified Rankin Scale ≤2) at 3 months.
  
  
  RESULTS
  We identified 77 patients with tandem occlusions. Recanalization occurred in 58 cases (75.3%) and parenchymal hematoma occurred in 8 cases (10.4%). Distal embolization occurred in 3 cases (3.9%). In 18 of 77 patients (23.4%), distal (ie, intracranial) recanalization was observed after proximal recanalization, obviating the need for distal intervention. Good clinical outcomes were achieved in 32 patients (41.6%). In multivariate analysis, Thrombolysis In Myocardial Ischemia ≥2 recanalization, baseline National Institutes of Health Stroke Scale score, baseline Alberta Stroke Programme Early CT score, and age were significantly associated with good outcome.
  
  
  CONCLUSIONS
  Endovascular therapy of tandem occlusions using extracranial internal carotid artery revascularization as the first step is technically feasible, has a high recanalization rate, and results in an acceptable rate of good clinical outcome. Future randomized, prospective studies should clarify the role of this approach.
authors.affiliation: UPMC Stroke Institute, 200 Lothrop Street, Suite C400, Pittsburgh, PA 15213, USA.
authors.forename: Amer M
authors.initials: AM
authors.lastname: Malik
authors.forename: Nirav A
authors.initials: NA
authors.lastname: Vora
authors.forename: Ridwan
authors.initials: R
authors.lastname: Lin
authors.forename: Syed F
authors.initials: SF
authors.lastname: Zaidi
authors.forename: Aitziber
authors.initials: A
authors.lastname: Aleu
authors.forename: Brian T
authors.initials: BT
authors.lastname: Jankowitz
authors.forename: Mouhammad A
authors.initials: MA
authors.lastname: Jumaa
authors.forename: Vivek K
authors.initials: VK
authors.lastname: Reddy
authors.forename: Maxim D
authors.initials: MD
authors.lastname: Hammer
authors.forename: Lawrence R
authors.initials: LR
authors.lastname: Wechsler
authors.forename: Michael B
authors.initials: MB
authors.lastname: Horowitz
authors.forename: Tudor G
authors.initials: TG
authors.lastname: Jovin
mesh_terms: D000368:Aged; D017130:Angioplasty / Q000379:methods; D002343:Carotid Artery, Internal / Q000473:pathology / Q000601:surgery*; D002548:Cerebral Revascularization / Q000379:methods; D002560:Cerebrovascular Circulation / Q000502:physiology*; D002561:Cerebrovascular Disorders / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D015607:Stents; D020521:Stroke / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000601:surgery*