Day 1 Extracranial Internal Carotid Artery Patency Is Associated With Good Outcome After Mechanical Thrombectomy for Tandem Occlusion

Механическая тромбэктомия в настоящее время является золотым стандартом в лечении острого ишемического инсульта при окклюзии крупных сосудов передней циркуляции мозгового кровообращения. Однако проблема лечения так называемой тандемной окклюзии - это одновременная окклюзия или критический стенозэкстракраниальной части внутренней сонной артерии (ВСА) в комбинации с окклюзией крупныхвнутримозговых сосудов передней циркуляции мозгового кровообращения в настоящее времяостается актуальной. В данной статье представлен клинический случай успешного лечения тандемной окклюзии внутренней сонной артерии и средней мозговой артерии путем проведения механической тромбэктомии с одномоментным стентированием внутренней сонной артерии. Однако для разработки единого стандарта лечения тандемных окклюзийнеобходимо проведение дальнейших исследований. Mechanical thrombectomy is currently the gold standard in the treatment of acute ischemic stroke with occlusion of large vessels of the anterior circulation of cerebral circulation. However, the problem of treating the so-called tandem occlusion is simultaneous occlusion or extracranial part of the internal carotid artery (ICA) critical stenosis in combination with occlusion of large intracerebral vessels of the anterior cerebral circulation currently remains relevant. This article presents a clinical case of successful treatment of tandem occlusion of the internal carotid artery and middle cerebral artery by mechanical thrombectomy with simultaneous ICA stenting. However, further research is needed to develop a unified standard for the tandem occlusions treatment.

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Acute thromboses and occlusions of dual layer carotid stents in endovascular treatment of tandem occlusions

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015032 ◽

2019 ◽

Vol 12 (1) ◽

pp. 33-37 ◽

Cited By ~ 3

Author(s):

Johannes A R Pfaff ◽

Christoph Maurer ◽

Erasmia Broussalis ◽

Hendrik Janssen ◽

Raphael Blanc ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Neurological Outcome ◽

Carotid Artery Stenting ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Thrombus Formation ◽

Extracranial Internal Carotid Artery ◽

Stent Occlusion ◽

Significant Difference

PurposeTo evaluate the occurrence and risk factors of acute in-stent thrombosis or stent occlusion in patients with tandem occlusions receiving intracranial mechanical thrombectomy and emergent extracranial internal carotid artery stenting with a dual layer carotid stent.MethodsMulticenter retrospective data collection and analysis of stroke databases of seven comprehensive stroke centers from three European countries.ResultsOverall, 160 patients (mean (SD) age 66 (12) years; 104 men (65%); median (IQR) baseline NIHSS 14 (9–18); IV lysis, n=97 (60.6%)) were treated for a cervical carotid artery occlusion or stenosis using a CASPER stent (MicroVention), and received mechanical thrombectomy for an intracranial occlusion between April 2014 and November 2018. During the procedure or within 72 hours, formation of thrombus and complete occlusion of the CASPER stent was observed in 33/160 (20.8%) and in 12/160 patients (7.5%), respectively. In 25/33 (75.8%) and in 9/12 patients (75%), respectively, this occurred during the procedure. No statistically significant difference was observed between patients with and without thrombus formation with regard to pre-existing long term medication with anticoagulants or intraprocedural administration of heparin, acetylsalicylic acid (ASA), or heparin and ASA. Favorable early neurological outcome was similar in patients with (n=15; 45.5%) and without (n=63; 49.6%) thrombus formation at the CASPER stent.ConclusionAcute thrombosis or occlusion of CASPER stents in thrombectomy patients receiving emergent extracranial internal carotid artery stenting for tandem occlusions were observed more often during the procedure than within 72 hours of follow-up, were less frequent then previously reported, and showed no impact on early neurological outcome.

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Mechanical Thrombectomy for Acute Middle Cerebral Artery Occlusion Caused by a Giant, Thrombosed, Extracranial Internal Carotid Artery Aneurysm

Journal of Clinical Neurology ◽

10.3988/jcn.2017.13.2.196 ◽

2017 ◽

Vol 13 (2) ◽

pp. 196

Author(s):

Odysseas Kargiotis ◽

Georgios Magoufis ◽

Apostolos Safouris ◽

Aristeidis H. Katsanos ◽

Eleftherios Stamboulis ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Artery Aneurysm ◽

Artery Occlusion ◽

Extracranial Internal Carotid Artery ◽

Carotid Artery Aneurysm ◽

Internal Carotid Artery Aneurysm ◽

Cerebral Artery Occlusion

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Emergent extracranial internal carotid artery stenting and mechanical thrombectomy in acute ischaemic stroke

Interventional Neuroradiology ◽

10.1177/1591019915583213 ◽

2015 ◽

Vol 21 (2) ◽

pp. 205-214 ◽

Cited By ~ 11

Author(s):

Ankit Mishra ◽

Hannah Stockley ◽

Tony Goddard ◽

Hemant Sonwalker ◽

Siddhartha Wuppalapati ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Ischaemic Stroke ◽

Cerebral Artery ◽

Acute Ischaemic Stroke ◽

Carotid Artery Stenting ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Extracranial Internal Carotid Artery ◽

Mean Time

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.

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Stenting of the cervical internal carotid artery in acute stroke management: The Karolinska experience

Interventional Neuroradiology ◽

10.1177/1591019916681983 ◽

2016 ◽

Vol 23 (2) ◽

pp. 159-165 ◽

Cited By ~ 19

Author(s):

Anastasios Mpotsaris ◽

Christoph Kabbasch ◽

Jan Borggrefe ◽

Vamsi Gontu ◽

Michael Soderman

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Retrospective Analysis ◽

Stent Placement ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Tissue Type ◽

Extracranial Internal Carotid Artery ◽

Anterior Circulation

Background Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre. Methods This was a retrospective analysis of all consecutive patients with acute extracranial carotid artery occlusion including acute dissection or high-grade stenosis and concomitant intracranial large-vessel occlusion treated with emergency carotid stenting and intracranial mechanical thrombectomy between November 2007 and May 2015. Results A total of 63 patients with a median age of 67 years (range 33–84 years) were treated. Of these, 33 (52%) patients had concomitant intravenous thrombolysis with recombinant tissue-type plasminogen activator initially. Median admission National Institutes of Health Stroke Scale was 14 (range 1–29). Median time from stroke onset to recanalization was 408 minutes (range 165–1846 minutes). Procedure time was significantly shorter after intravenous thrombolysis (110 minutes [range 15–202 minutes] vs. 130 minutes [range 60–280 minutes]; p = 0.02). Three (5%) patients experienced post-procedural symptomatic intracerebral haemorrhage. In 55/63 (87%) patients, a score of ≥2b on the Thrombolysis in Cerebral Infarction scale could be achieved. Eight (13%) patients died, five (8%) during the acute phase. A total of 29/63 (46%) patients showed a favourable outcome (modified Rankin Scale score of 0–2) after three months. Conclusions Our single-centre retrospective analysis of emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy demonstrated high technical success, reasonable clinical outcomes and acceptable rates of symptomatic intracranial haemorrhage in carefully chosen patients which are triaged interdisciplinary based on clinical and computed tomography imaging criteria. This warrants further study in a randomised prospective trial.

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Utility of Hounsfield unit in the diagnosis of tandem occlusion in acute ischemic stroke

Neurological Sciences ◽

10.1007/s10072-020-04798-4 ◽

2020 ◽

Author(s):

Ruben Mühl-Benninghaus ◽

Julia Dressler ◽

Alena Haußmann ◽

Andreas Simgen ◽

Wolfgang Reith ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Imaging Modality ◽

Characteristic Curve ◽

Hounsfield Unit ◽

Extracranial Internal Carotid Artery ◽

Stroke Treatment ◽

Tandem Occlusion ◽

Significant Difference

Abstract Background Tandem occlusions can complicate medical and endovascular stroke treatment. To identify these occlusions, computed tomography angiography (CTA) represents the best imaging modality. However, CTA is still not initially performed in some patients not admitted directly to stroke centers. Early identification of an additional occlusion of the proximal extracranial internal carotid artery may improve the best suitable treatment strategy. The purpose of this study was to find a valuable threshold of thrombus attenuation in a non-contrast head CT (NCCT) scan to facilitate a safe diagnosis of tandem occlusions. Materials and methods Consecutive patients with acute middle cerebral artery (MCA) occlusions who underwent endovascular treatment were identified from our registry of neuroendovascular interventions. Thrombus attenuations of the affected MCA and contralateral vessel were measured by NCCT. To compare individual baseline blood attenuations, the difference between the thrombus attenuation and the contralateral MCA attenuation (referred to as ΔTM) was calculated. Results Three hundred and twenty-five patients were included. There was a highly significant difference between mean thrombus attenuation with isolated MCA occlusion and additional extracranial internal carotid artery (ICA) occlusion (49.9 ± 8 vs. 56.2 ± 10 Hounsfield units (HU); P < 0.001). The area under the receiver operating characteristic curve of ΔTM was 0.72. The optimal threshold value was 13.5 HU, with a sensitivity of 67.5% and a specificity of 68.6%. Conclusion Despite a significant difference in thrombus attenuation in MCA occlusions with an additional extracranial ICA occlusion compared with isolated MCA occlusions, a relevant threshold of thrombus attenuation was not found.

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Effect of emergent carotid stenting during endovascular therapy for acute anterior circulation stroke patients with tandem occlusion: A multicenter, randomized, clinical trial (TITAN) protocol

International Journal of Stroke ◽

10.1177/1747493020929948 ◽

2020 ◽

pp. 174749302092994 ◽

Cited By ~ 1

Author(s):

François Zhu ◽

Gabriela Hossu ◽

Marc Soudant ◽

Sébastien Richard ◽

Hamza Achit ◽

...

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Acute Ischemic Stroke ◽

Antiplatelet Therapy ◽

Carotid Artery Stenting ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Anterior Circulation ◽

Tandem Occlusion

Background and hypothesis There is no consensus on the optimal endovascular management of the extracranial internal carotid artery steno-occlusive lesion in patients with acute ischemic stroke due to tandem occlusion. We hypothesized that intracranial mechanical thrombectomy plus emergent internal carotid artery stenting (and at least one antiplatelet therapy) is superior to intracranial mechanical thrombectomy alone in patients with acute tandem occlusion. Study design TITAN is an investigator-initiated, multicenter, prospective, randomized, open-label, blinded-endpoint (PROBE) study. Eligibility requires a diagnosis of acute ischemic stroke, pre-stroke modified Rankin Scale (mRS)≤2 (no upper age limit), National Institutes of Health Stroke Scale (NIHSS)≥6, Alberta Stroke Program Early Computed Tomography Score (ASPECTS)≥6, and tandem occlusion on the initial catheter angiogram. Tandem occlusion is defined as large vessel occlusion (intracranial internal carotid artery , M1 and/or M2 segment) and extracranial severe internal carotid artery stenosis ≥90% (NASCET) or complete occlusion. Patients are randomized in two balanced parallel groups (1:1) to receive either intracranial mechanical thrombectomy plus internal carotid artery stenting (and at least one antiplatelet therapy) or intracranial mechanical thrombectomy alone within 8 h of stroke onset. Up to 432 patients are randomized after tandem occlusion confirmation on angiogram. Study outcomes The primary outcome measure is complete reperfusion rate at the end of endovascular procedure, assessed as a modified Thrombolysis in Cerebral Infarction (mTICI) 3, and ≥4 point decrease in NIHSS at 24 h. Secondary outcomes include infarct growth, recurrent clinical ischemic event in the ipsilateral carotid territory, type and dose of antiplatelet therapy used, mRS at 90 (±15) days and 12 (±1) months. Safety outcomes are procedural complications, stent patency, intracerebral hemorrhage, and death. Economics analysis includes health-related quality of life, and costs utility comparison, especially with the need or not of endarterectomy. Discussion TITAN is the first randomized trial directly comparing two types of treatment in patients with acute ischemic stroke due to anterior circulation tandem occlusion, and especially assessing the safety and efficacy of emergent internal carotid artery stenting associated with at least one antiplatelet therapy in the acute phase of stroke reperfusion. Trial registration ClinicalTrials.gov NCT03978988

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