title: Two in One: Endovascular Treatment of Acute Tandem Occlusions in the Anterior Circulation.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Klinik für Neuroradiologie, Universitätsklinik Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany. christoph.johannes.maurer@uniklinik-freiburg.de.
authors.forename: C J
authors.initials: CJ
authors.lastname: Maurer
authors.affiliation: Klinik für Neurologie, Klinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
authors.forename: F
authors.initials: F
authors.lastname: Joachimski
authors.affiliation: Klinik für diagnostische Radiologie und Neuroradiologie, Klinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Berlis
mesh_terms: D000368:Aged; D020520:Brain Infarction / Q000000981:diagnostic imaging* / Q000601:surgery*; D016893:Carotid Stenosis / Q000000981:diagnostic imaging* / Q000601:surgery*; D002533:Cerebral Angiography / Q000379:methods; D002548:Cerebral Revascularization / Q000295:instrumentation / Q000379:methods; D003131:Combined Modality Therapy / Q000295:instrumentation / Q000379:methods; D057510:Endovascular Procedures / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D061185:Mechanical Thrombolysis / Q000295:instrumentation / Q000379:methods*; D015607:Stents; D025321:Surgery, Computer-Assisted / Q000379:methods; D016896:Treatment Outcome
keywords: Stent; Stroke; Tandem occlusion; Thrombectomy