title: Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandem occlusive disease.
abstract: OBJECTIVE
  Acute tandem occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. We describe our experience with emergency stent-assisted ICA angioplasty and intracranial stent-based thrombectomy of tandem occlusions.
  
  
  METHODS
  Procedures were performed from March 2010 to December 2013. National Institutes of Health Stroke Score (NIHSS) and Alberta Stroke Program Early CT Score (ASPECTS), occlusion sites, collateral supply, procedural details, and outcomes were retrospectively reviewed with IRB waiver of informed consent.
  
  
  RESULTS
  24 patients, mean age 66 years, mean admission NIHSS 20.4, and mean ASPECTS 9 were included. Occlusion sites were proximal ICA-middle cerebral artery (MCA) trunk in 17 patients, proximal ICA-ICA terminus in six, and ICA-MCA-anterior cerebral artery in one. Stent-assisted cervical ICA recanalization was achieved in all patients, with unprotected pre-angioplasty in 24/24, unprotected stenting in 16/24 (67%), and protected stenting in 8/24 (33%), followed by stent-thrombectomy in 25 intracranial occlusions. There was complete recanalization/complete perfusion in 19/24 (79%), complete recanalization/partial perfusion in 3/24 (13%), and partial recanalization/partial perfusion in 2/24 (8%) with no procedural morbidity/mortality. Mean time to therapy was 3.8 h (range 2-5.5) and mean time to recanalization was 51 min (range 38-69). At 3-month follow-up, among 17/22 surviving patients (77%), 13/17 (76%) were modified Rankin Scale (mRS) 0-2 and 3/17 (18%) were mRS 3.
  
  
  CONCLUSIONS
  In acute tandem ICA-MCA/distal ICA occlusions, extracranial stenting followed by intracranial stent-based thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.
authors.affiliation: Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: José E
authors.initials: JE
authors.lastname: Cohen
authors.affiliation: Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: J Moshe
authors.initials: JM
authors.lastname: Gomori
authors.affiliation: Department of Neurosurgery, Sheba Medical Center, Tel Aviv, Israel.
authors.forename: Gustavo
authors.initials: G
authors.lastname: Rajz
authors.affiliation: Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Eyal
authors.initials: E
authors.lastname: Itshayek
authors.affiliation: Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Roni
authors.initials: R
authors.lastname: Eichel
authors.affiliation: Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Ronen R
authors.initials: RR
authors.lastname: Leker
mesh_terms: D000368:Aged; D017130:Angioplasty / Q000379:methods*; D001157:Arterial Occlusive Diseases / Q000473:pathology / Q000601:surgery*; D002342:Carotid Artery, External / Q000473:pathology / Q000601:surgery*; D002343:Carotid Artery, Internal / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000473:pathology / Q000601:surgery*; D017063:Outcome Assessment, Health Care; D015607:Stents; D017131:Thrombectomy / Q000379:methods*
keywords: Artery; Stent; Stroke; Technique; Thrombectomy