title: Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results.
abstract: BACKGROUND
  Acute tandem occlusions of the cervical and distal internal carotid artery (ICA) or middle cerebral artery (MCA) are associated with major stroke with intravenous (i.v.) thrombolysis alone in approximately 90 % of patients. The data on endovascular management of tandem occlusions is still limited. The purpose of this study was to review technical aspects and the current state of the literature on acute ICA stenting in combination with stent retriever-based intracranial thrombectomy.
  
  
  METHODS
  We retrospectively reviewed the data of 37 consecutive patients with tandem occlusions including clinical parameters, angiographic results, procedural aspects, complications, and hemorrhages.
  
  
  RESULTS
  Median National Institutes of Health Stroke Scale (NIHSS) on admission was 17 (3-30). Intracranial thrombectomy was performed prior to ICA stenting in 25/37 (67.6 %) and after stenting in 12/37 (32.4 %) patients. ICA stenting was successful in all cases, and a thrombolysis in cerebral infarction (TICI) scale 2b/3 result was achieved in 27/37 (73 %) cases. The mean angiography time was significantly shorter in the "thrombectomy first" group (43.1 ± 30.8 vs. 110.8 ± 43.0 min, p < 0.001), and more patients had favorable outcomes after 3 months (13/25 = 52.0 vs. 4/12 = 33.3 %, p = 0.319). In this group, intermediate catheters were used and successfully prevented embolism to unaffected territories in all cases.
  
  
  CONCLUSIONS
  Acute stenting of the cervical ICA in combination with intracranial thrombectomy was technically feasible and safe in our series. Thrombectomy prior to proximal stenting was associated with shorter reperfusion times and a tendency towards better clinical outcome leading to a good outcome in about 50 % of the patients. Therefore, we recommend this approach in tandem occlusion requiring stent angioplasty.
authors.affiliation: Department of Radiology, University Hospital of Cologne, Kerpenerstr. 62, 50937, Cologne, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Lockau
authors.forename: T
authors.initials: T
authors.lastname: Liebig
authors.forename: T
authors.initials: T
authors.lastname: Henning
authors.forename: V
authors.initials: V
authors.lastname: Neuschmelting
authors.forename: H
authors.initials: H
authors.lastname: Stetefeld
authors.forename: C
authors.initials: C
authors.lastname: Kabbasch
authors.forename: F
authors.initials: F
authors.lastname: Dorn
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty; D002343:Carotid Artery, Internal; D005260:Female; D006801:Humans; D020767:Intracranial Thrombosis / Q000150:complications / Q000628:therapy*; D008297:Male; D061185:Mechanical Thrombolysis; D008875:Middle Aged; D020768:Middle Cerebral Artery; D012189:Retrospective Studies; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000628:therapy; D016896:Treatment Outcome