title: Emergent extracranial internal carotid artery stenting and mechanical thrombectomy in acute ischaemic stroke.
abstract: OBJECTIVE
  Tandem occlusions involving both the extracranial internal carotid artery (ICA) and an intracranial artery typically respond poorly to intravenous (IV) tissue plasminogen activator (t-PA). We retrospectively review our experience with proximal ICA stenting and stent-assisted thrombectomy of the distal artery.
  
  
  METHODS
  The data included patients that underwent carotid stenting and mechanical thrombectomy between 2012-2013. Radiographic, clinical, and procedural data were drawn from case notes, imaging records and discharge reports. Clinical outcomes were evaluated using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale (mRs).
  
  
  RESULTS
  Seven patients, with a mean age of 66.4 years and a mean admission NIHSS of 18.3, underwent this procedure and were included. Each presented with an occlusion of the proximal ICA, with additional occlusions of the ICA terminus (n = 3), middle cerebral artery (n = 5), or anterior cerebral artery (n = 1). Recanalisation of all identified occlusions was achieved in all patients, with a Thrombolysis in Myocardial Infarction (TIMI) score of 3 and a Thrombolysis in Cerebral Infarction (TICI) score >2b achieved in each case. Mean time from onset of stroke symptoms to recanalisation was 287 min; mean time from first angiography to recanalisation was 52 min. Intracranial haemorrhages occurred in two patients, with no increase in NIHSS. There were no mortalities. Mean NIHSS at discharge was 4.9, and mRs at 90 days was one in all patients.
  
  
  CONCLUSIONS
  Treatment of tandem extracranial ICA and intracranial occlusions in the setting of acute ischaemic stroke with extracranial carotid artery stenting followed by adjunctive intracranial mechanical thrombectomy is both safe and effective, but further evaluation of this treatment modality is necessary.
authors.affiliation: GKT School of Medical Education, King's College London, UK.
authors.forename: Ankit
authors.initials: A
authors.lastname: Mishra
authors.affiliation: MRI Department, Leeds General Infirmary, UK.
authors.forename: Hannah
authors.initials: H
authors.lastname: Stockley
authors.affiliation: MRI Department, Leeds General Infirmary, UK.
authors.forename: Tony
authors.initials: T
authors.lastname: Goddard
authors.affiliation: Radiology, Royal Preston Hospital, UK.
authors.forename: Hemant
authors.initials: H
authors.lastname: Sonwalker
authors.affiliation: Radiology, Royal Preston Hospital, UK.
authors.forename: Siddhartha
authors.initials: S
authors.lastname: Wuppalapati
authors.affiliation: MRI Department, Leeds General Infirmary, UK tufail.patankar@btinternet.com.
authors.forename: Tufail
authors.initials: T
authors.lastname: Patankar
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000601:surgery*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging / Q000601:surgery*; D002533:Cerebral Angiography; D002544:Cerebral Infarction / Q000601:surgery; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000601:surgery; D012189:Retrospective Studies; D015607:Stents; D020521:Stroke / Q000000981:diagnostic imaging / Q000601:surgery*; D017131:Thrombectomy / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: Stroke; carotid artery; internal; intracranial thrombosis; stents; thrombectomy