title: Management of acute ischemic stroke due to tandem occlusion: should endovascular recanalization of the extracranial or intracranial occlusive lesion be done first?
abstract: OBJECTIVE Acute tandem occlusions of the cervical internal carotid artery and an intracranial large vessel present treatment challenges. Controversy exists regarding which lesion should be addressed first. The authors sought to evaluate the endovascular approach for revascularization of these lesions at Gates Vascular Institute. METHODS The authors performed a retrospective review of a prospectively maintained, single-institution database. They analyzed demographic, procedural, radiological, and clinical outcome data for patients who underwent endovascular treatment for tandem occlusions. A modified Rankin Scale (mRS) score ≤ 2 was defined as a favorable clinical outcome. RESULTS Forty-five patients were identified for inclusion in the study. The average age of these patients was 64 years; the mean National Institutes of Health Stroke Scale score at presentation was 14.4. Fifteen patients received intravenous thrombolysis before undergoing endovascular treatment. Thirty-seven (82%) of the 45 proximal cervical internal carotid artery occlusions were atherothrombotic in nature. Thirty-eight patients underwent a proximal-to-distal approach with carotid artery stenting first, followed by intracranial thrombectomy, whereas 7 patients underwent a distal-to-proximal approach (that is, intracranial thrombectomy was performed first). Thirty-seven (82%) procedures were completed with local anesthesia. For intracranial thrombectomy procedures, aspiration alone was used in 15 cases, stent retrieval alone was used in 5, and a combination of aspiration and stent-retriever thrombectomy was used in the remaining 25. The average time to revascularization was 81 minutes. Successful recanalization (thrombolysis in cerebral infarction Grade 2b/3) was achieved in 39 (87%) patients. Mean National Institutes of Health Stroke Scale scores were 9.3 immediately postprocedure (p < 0.05) (n = 31), 5.1 at discharge (p < 0.05) (n = 31), and 3.6 at 3 months (p < 0.05) (n = 30). There were 5 in-hospital deaths (11%); and 2 patients (4.4%) had symptomatic intracranial hemorrhage within 24 hours postprocedure. Favorable outcomes (mRS score ≤ 2) were achieved at 3 months in 22 (73.3%) of 30 patients available for follow-up, with an mRS score of 3 for 7 of 30 (23%) patients. CONCLUSIONS Tandem occlusions present treatment challenges, but high recanalization rates were possible in the present series using acute carotid artery stenting and mechanical thrombectomy concurrently. Proximal-to-distal and aspiration approaches were most commonly used because they were safe, efficacious, and feasible. Further study in the setting of a randomized controlled trial is needed to determine the best sequence for the treatment approach and the best technology for tandem occlusion.
authors.affiliation: Departments of 1 Neurosurgery.|Department of Neurosurgery, Gates Vascular Institute at Kaleida Health.|Department of Neurosurgery, Wayne State School of Medicine, Wayne State University, Detroit, Michigan.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Rangel-Castilla
authors.affiliation: Department of Neurosurgery, Wayne State School of Medicine, Wayne State University, Detroit, Michigan.
authors.forename: Gary B
authors.initials: GB
authors.lastname: Rajah
authors.affiliation: Departments of 1 Neurosurgery.|Department of Neurosurgery, Gates Vascular Institute at Kaleida Health.
authors.forename: Hakeem J
authors.initials: HJ
authors.lastname: Shakir
authors.affiliation: Departments of 1 Neurosurgery.|Department of Neurosurgery, Gates Vascular Institute at Kaleida Health.
authors.forename: Hussain
authors.initials: H
authors.lastname: Shallwani
authors.affiliation: Neurology, Jacobs School of Medicine and Biomedical Sciences, and.|Department of Neurosurgery, Gates Vascular Institute at Kaleida Health.
authors.forename: Sirin
authors.initials: S
authors.lastname: Gandhi
authors.affiliation: Departments of 1 Neurosurgery.|Biomedical Informatics.|Department of Neurosurgery, Gates Vascular Institute at Kaleida Health.
authors.forename: Jason M
authors.initials: JM
authors.lastname: Davies
authors.affiliation: Departments of 1 Neurosurgery.|Neurology, Jacobs School of Medicine and Biomedical Sciences, and.|Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York.|Department of Neurosurgery, Gates Vascular Institute at Kaleida Health.
authors.forename: Kenneth V
authors.initials: KV
authors.lastname: Snyder
authors.affiliation: Departments of 1 Neurosurgery.|Radiology, and.|Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York.|Department of Neurosurgery, Gates Vascular Institute at Kaleida Health.
authors.forename: Elad I
authors.initials: EI
authors.lastname: Levy
authors.affiliation: Departments of 1 Neurosurgery.|Radiology, and.|Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York.|Department of Neurosurgery, Gates Vascular Institute at Kaleida Health.|Jacobs Institute, Buffalo, New York; and.
authors.forename: Adnan H
authors.initials: AH
authors.lastname: Siddiqui
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000150:complications; D002342:Carotid Artery, External / Q000000981:diagnostic imaging / Q000601:surgery*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging / Q000601:surgery*; D019468:Disease Management; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D059906:Neuroimaging; D012189:Retrospective Studies; D020521:Stroke / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D016896:Treatment Outcome
keywords: CCA = common carotid artery; ICA = internal carotid artery; ICH = intracranial hemorrhage; IV = intravenous; MCA = middle cerebral artery; NIHSS = National Institutes of Health Stroke Scale; TICI = thrombolysis in cerebral infarction; acute ischemic stroke; aspiration; carotid artery occlusion; carotid artery stenting; mRS = modified Rankin Scale; mechanical thrombectomy; tPA = tissue plasminogen activator; tandem occlusion