title: Emergent stent-assisted angioplasty of extracranial internal carotid artery and intracranial stent-based thrombectomy in acute tandem occlusive disease: technical considerations.
abstract: OBJECTIVE
  Tandem occlusions of the internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous thrombolytic therapy, and are usually managed by endovascular means. This study describes experience with stent-assisted endovascular ICA revascularization and stent-based thrombectomy.
  
  
  METHODS
  In patients with tandem ICA-middle cerebral artery (MCA)/distal ICA occlusion, the carotid occlusion was recanalized by primary angioplasty and stent implantation, and the distal occlusion by stent-based thrombectomy. Two variant techniques are described.
  
  
  RESULTS
  Seven consecutive patients, mean age 64.1 years (range 49-75) and mean admission National Institutes of Health Stroke Scale score of 23, were included. Occlusion sites were tandem proximal ICA and MCA trunk (six patients) and tandem proximal left ICA and ICA terminus (one patient). Complete recanalization with complete perfusion (Thrombolysis in Myocardial Infarction [TIMI] 3, Thrombolysis in Cerebral Infarction [TICI] 3) was achieved in six patients and partial recanalization with partial perfusion (TIMI 2, TICI 2A) in one. Mean time to therapy was 4.9 h (range 3-6.5); mean time to recanalization was 55 min (range 38-65 min). CT performed 1 day after recanalization showed cortical sparing (>90% of the cortex at risk) in seven patients. Five patients (72%) presented with good clinical outcome (modified Rankin Scale (mRS) score 0-2) at 1 month; one patient (patient No 7) reached an mRS score of 3 and one patient died.
  
  
  CONCLUSIONS
  In selected cases of acute ICA occlusion and concomitant major vessel embolic stroke, angioplasty and stenting of the proximal occlusion and stent-based thrombectomy of the intracranial occlusion may be feasible, effective and safe, and provide early neurological improvement. Further experience and prospective studies are warranted.
authors: Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. jcohenns@yahoo.com
authors: José E
authors: JE
authors: Cohen
authors: Moshe
authors: M
authors: Gomori
authors: Gustavo
authors: G
authors: Rajz
authors: Samuel
authors: S
authors: Moscovici
authors: Ronen R
authors: RR
authors: Leker
authors: Shai
authors: S
authors: Rosenberg
authors: Eyal
authors: E
authors: Itshayek
mesh_terms: D000368:Aged; D017130:Angioplasty / Q000379:methods*; D001157:Arterial Occlusive Diseases / Q000601:surgery*; D002545:Brain Ischemia / Q000150:complications / Q000601:surgery; D002343:Carotid Artery, Internal / Q000601:surgery*; D002533:Cerebral Angiography; D002544:Cerebral Infarction / Q000150:complications / Q000601:surgery; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000601:surgery; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000601:surgery; D009460:Neurologic Examination; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000601:surgery; D017131:Thrombectomy / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome