title: Endovascular treatment of tandem internal carotid and middle cerebral artery occlusions.
abstract: OBJECTIVE
  Extracranial internal carotid artery (ICA) angioplasty and intracranial thrombectomy may be a safe and efficacious therapeutic option for recanalization of a subset of arterial occlusions termed tandem occlusions of Internal carotid artery and Middle cerebral artery (TIM).
  
  
  BACKGROUND
  Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant ICA occlusion and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. We report our experience on acute ischemic stroke patients with TIM occlusion treated with extracranial ICA angioplasty/stenting and intracranial thrombectomy and/or standard intravenous thrombolysis.
  
  
  METHODS
  A retrospective analysis of 7 patients from our stroke database was done. 6 patients of the 7 patients were treated with extracranial ICA angioplasty and intracranial thrombectomy and/or intravenous thrombolysis. We examined early neurological improvement (defined by a reduction of National Institutes of Health Stroke Scale (NIHSS) > 8 points). We also evaluated the rate of successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2b or 3.
  
  
  RESULTS
  All but one of the 6 treated patients achieved a TICI score of 2b or 3 signifying successful recanalization. In addition, treated patients had an early reduction of their NIHSS by greater than 8 points. The 1 patient who did not to achieve TICI 2b or 3 also failed to show early neurological improvement. Four of the treated patients had a follow up NIHSS at 90 days of 1 or less and mRS at 90 days of 0.
  
  
  CONCLUSIONS
  In cases of tandem occlusions of ICA and MCA, multimodal therapy consistent of intravenous thrombolysis and/or extracranial ICA stenting and intracranial thrombectomy to achieve recanalization may be a safe and efficacious therapeutic option for recanalization. Further prospective studies are warranted.
authors.affiliation: Authors Contributed equally ; - JFK New Jersey Neuroscience Institute at Seton Hall University, Edison, NJ.
authors.forename: Haitham
authors.initials: H
authors.lastname: Dababneh
authors.affiliation: Authors Contributed equally ; - JFK New Jersey Neuroscience Institute at Seton Hall University, Edison, NJ.
authors.forename: Asif
authors.initials: A
authors.lastname: Bashir
authors.affiliation: Authors Contributed equally ; - JFK New Jersey Neuroscience Institute at Seton Hall University, Edison, NJ.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Hussain
authors.affiliation: - University of Texas Health Science Center, Houston, TX.
authors.forename: Waldo R
authors.initials: WR
authors.lastname: Guerrero
authors.affiliation: - Neurology, University of Florida, Gainesville, FL.
authors.forename: Walter
authors.initials: W
authors.lastname: Morgan
authors.affiliation: - Neurology, University of Florida, Gainesville, FL.
authors.forename: Anna Yuzefovich
authors.initials: AY
authors.lastname: Khanna
authors.affiliation: - Neurosurgery, Vanderbilt University, Nashville, TN.
authors.forename: J Duffy
authors.initials: JD
authors.lastname: Mocco