title: Outcome after mechanical thrombectomy using a stent retriever under conscious sedation: comparison between tandem and single occlusion of the anterior circulation.
abstract: OBJECTIVE
  In acute ischemic stroke patients, internal carotid artery/middle cerebral artery (ICA/MCA) occlusion in tandem predicts a poor outcome after systemic thrombolysis. This study aimed to compare outcomes after mechanical thrombectomy for tandem and single occlusions of the anterior circulation.
  
  
  METHODS
  This prospective study included consecutive patients with acute ischemic stroke of the anterior circulation who had undergone mechanical thrombectomy performed with a stent retriever under conscious sedation within 6h of symptom onset. Data on clinical, imaging and endovascular findings were collected. In cases of tandem occlusion, distal thrombectomy (retrograde approach) was performed first whenever possible. Tandem and single occlusions were compared in terms of functional outcome and mortality at 3 months.
  
  
  RESULTS
  From May 2010 to April 2012, 42 patients with acute ischemic stroke attributable to MCA and/or ICA occlusion were treated. Eleven patients (26.2%) presented with tandem occlusions and 31 patients (73.8%) had a single anterior circulation occlusion. Baseline characteristics were similar between the two groups. Recanalization status also did not differ significantly (P=0.76), but patients with tandem occlusions had poorer functional outcomes (18.2% vs. 67.7% for single occlusions; P=0.01), a higher mortality rate at 3 months (45.5% vs. 12.9%, respectively; P=0.03) and more symptomatic intracranial hemorrhages at 24h (9.7% vs. 0%, respectively; P=0.01). A high rate of early proximal re-occlusion or severe residual stenosis (66%) was also observed in the tandem group.
  
  
  CONCLUSIONS
  Tandem occlusions had poor clinical outcomes after mechanical thrombectomy compared with single occlusions. The retrograde approach (treatment of distal occlusion first) used in patients under conscious sedation may have contributed to these poor outcomes.
authors.affiliation: Service de radiologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France.
authors.forename: Sébastien
authors.initials: S
authors.lastname: Soize
authors.affiliation: Service de radiologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France.
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Kadziolka
authors.affiliation: Service de radiologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France.
authors.forename: Laurent
authors.initials: L
authors.lastname: Estrade
authors.affiliation: Service de neurologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Serre
authors.affiliation: Unité d'aide méthodologique, pôle recherche et innovations, université de Reims, hôpital Robert-Debré, rue du Généra-Koening, 51100 Reims, France.
authors.forename: Coralie
authors.initials: C
authors.lastname: Barbe
authors.affiliation: Service de radiologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France. Electronic address: lpierot@gmail.com.
authors.forename: Laurent
authors.initials: L
authors.lastname: Pierot
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000628:therapy*; D016292:Procedural Sedation; D020878:Device Removal / Q000295:instrumentation*; D019544:Equipment Failure Analysis; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000628:therapy*; D008297:Male; D061185:Mechanical Thrombolysis / Q000295:instrumentation*; D011474:Prosthesis Design; D011859:Radiography; D015607:Stents; D016896:Treatment Outcome
keywords: Conscious sedation; Endovascular procedures; Mechanical thrombolysis; Stroke; Tandem; Thrombectomy