- Email: [email protected]
Endovascular treatment of acute tandem occlusion strokes and stenting first experience
Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical note
Endovascular treatment of acute tandem occlusion strokes and stenting first experience Süha Akpınar a, Pınar Gelener b,c,⇑ a
Radiology Department, Near East University Faculty of Medicine, Nicosia, North Cyprus, Mersin 10, Turkey Neurology Department, Kyrenia University Dr. Suat Günsel Faculty of Medicine, North Cyprus, Mersin 10, Turkey c Near East University Faculty of Medicine, Nicosia, North Cyprus, Mersin 10, Turkey b
a r t i c l e
i n f o
Article history: Received 13 March 2017 Accepted 18 September 2017 Available online xxxx Keywords: Tandem strokes Stent first Endovascular treatment
a b s t r a c t This study demonstrates the radiologic and clinical findings, etiologies and intervention strategy in 8 acute ischemic stroke patients with tandem occlusions. The mean age was 57 and mean NIHSS score was 19. Stent-assisted thrombectomy (SAT) was performed on all of the patients. Additionally, 6 patients underwent carotid artery stenting before SAT. Recanalization with TICI 2b was attained in 7/8 patients. The 90th day median mRS was 2 and mortality was 1/8. The etiologies of the tandem occlusions were either extracranial high grade ICA stenosis/occlusion or cervical ICA dissection. When the stent-first approach was applied with distal thrombectomy, high TICI and low mRS scores were obtained. Ó 2017 Elsevier Ltd. All rights reserved.
1. Introduction Acute tandem occlusion is generally defined as concomitant stenosis/occlusions of the cervical ICA and MCA. However, it was defined as terminal ICA with M1-MCA involvement in the REVASCAT trial and ICA occlusion with the involvement of M1-MCA occlusion in the MR CLEAN trial [1,2]. Among acute stroke patients, 10–20% of them have additional occlusions or stenosis of the ipsilateral cervical internal carotid artery [3]. In those patients, the recanalization rate is limited to 5.9% with only intravenous thrombolysis (IVT) [4]. Resultantly, these so-called tandem occlusions are preferably treated with endovascular interventions. There are mainly two endovascular treatment options that have been described. In the proximal to distal approach, the proximal occlusion is recanalized first by either stenting or balloon angioplasty, followed by distal mechanical thrombectomy [5]. In the distal to proximal approach, a stent assisted thrombectomy (SAT) is performed first at the distal MCA and/or ACA occlusion site. There is an increasing amount of data on emergency ICA stenting and intracranial thrombectomy reinforcing the therapeutic value of endovascular interventions in the latest trials [6]. However, the optimal selection of patients and the preferred technique of intervention of this group are still a cause for debate. According to the
⇑ Corresponding author at: Department of Neurology, Kyrenia University Dr. Suat Günsel Faculty of Medicine, North Cyprus, Mersin 10, Turkey. E-mail address: [email protected] (P. Gelener).
latest ESO-Karolinska Stroke Update Conference, acute stenting of the occlusion site has resulted in higher recanalization rates and favourable outcomes [7]. The aim of this study is to evaluate the results of endovascular treatment of acute tandem occlusions in a patient group with the stent-first approach and to discuss the course of intervention, recanalization rates, procedural complications and clinical outcomes in respect to the literature.
2. Materials and methods Clinical presentation, imaging and procedural data of all 70 consecutive patients who were subjected to endovascular treatment for acute ischemic stroke, within a four year period (between 2012 and 2016) were collected retrospectively. The inclusion criteria were: patients admitted within 6 h of symptom onset, exclusion of haemorrhage at plain CT, CT signs of ischemia less than 1/3 of the MCA territory, findings of tandem occlusion of the intracranial MCA and ICA stenosis/occlusion on DSA. The institutional human investigation review board did not exist when the study was initiated. Hence, the principles of the Declaration of Helsinki were followed. National Institutes of Health Stroke Scale (NIHSS) scores were noted at the time of admission. None of the patients received intravenous thrombolysis. Non-contrast CT and CTA (Somatom Sensation 16, Siemens, Germany) were followed by monoplanar DSA (Allura Xper FD20, Philips, Netherlands) guided intervention. General anesthesia was administered on all patients.
https://doi.org/10.1016/j.jocn.2017.09.010 0967-5868/Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Akpınar S, Gelener P. Endovascular treatment of acute tandem occlusion strokes and stenting first experience. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.09.010
2
S. Akpınar, P. Gelener / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
All CTA findings were evaluated by a single European board certified neuroradiologist with 5 years’ experience on stroke imaging. An 8 Fr introducer was usually placed into the puncture site for an anterior circulation stroke, followed by a Simmons 2 catheter (Stryker Neurovascular, USA) or vertebral catheter 100/125 cm (Cook, USA) to engage the supra-aortic arteries. A Terumo stiff guidewire (Terumo, Tokyo, Japan) was used to launch the 8 Fr Corail balloon-guiding catheter (Balt, France) to the main arteries. According to the initial DSA findings, endovascular proximal ICA stenting was planned before the thrombectomy procedure. The ICA stent was launched without a protection device. In cases with insufficient stent opening, post-stenting balloon angioplasty by using a 6 mm 40 mm balloon following ICA stenting was performed. The Solitaire (FR Covidien/ev3 Inc., Irvine, USA) stent retriever was used only for the SAT. Wallstent (Boston Scientific, USA) was used for internal carotid artery stenting (CAS). Systemic anticoagulation was supplied by 5000 IU of heparin to patients on whom primary stenting was performed. They also received the loading dose of clopidogrel after stent implantation. Nimodipine infusion was additionally used to prevent cerebral vasospasm. Reperfusion success was rated on the basis of the thrombolysis in the cerebral infarction (TICI) scale (successful reperfusion defined as TICI scores 2b and 3). The modified Rankin scale (mRS) was documented 3 months after stroke onset. Good clinical outcomes were defined as mRS 0–2.
3. Results Overall, 70 patients underwent endovascular treatment. Eight (11.4%) of them (2 female, 6 male) had tandem occlusions. The mean age was 57 with a range from 23 and 74 years and the median NIHSS at admission was 19 (range from 11 to 25 points) (Table 1). Initial CTAs revealed a high-grade stenosis/occlusion of the cervical ICA in all patients. DSA showed high grade extracranial carotid stenosis in 5 patients (Fig. 1) and extracranial dissection in 3 patients. Intracranial occlusion sites documented by DSA were MCA-M1 in all patients (Fig. 3) and additional ACA-A1 occlusion was observed in 3 patients (Table 1). All of the 8 patients went through SAT. Carotid artery stenting was performed in 6 out of the 8 patients with the stenting-first (proximal to distal) approach before SAT. These patients included 5 with high grade ICA stenosis and 1 with cervical ICA dissection (Fig. 2) (Table 1). Resultantly, successful reperfusion (TICI 2b/3) was achieved in 7/8 patients. The duration of the CAS session was between 7 and 15 min. Procedural complications were; stent re-occlusion and parenchymal haemorrhage type 2. At discharge, 7/8 patients had a favourable to moderate outcome (mRS 0–3). Median mRS at discharge was 2. Only 1 out of the 8 patients died during his initial hospital stay. After 3 months, the median mRS remained at 2 (range 1–6). Of these, minimal or no disability (mRS between 0 and 1) was found in 2 patients and 3
Fig. 1. Digital subtraction image of the right internal carotid artery occlusion showing no flow to the distal internal carotid artery and distal vessels.
patients had a favourable clinical outcome (mRS 2). Two patients had moderate to severe disability with an mRS of 3 and 4 and one patient died (Table 1). 4. Discussion Of the 70 patients who underwent endovascular treatment 8 (11.4%) of them had tandem occlusions in the patient group studied. Three of them had additional ACA occlusion. The number of tandem occlusions was 26/102 (25.5%) terminal ICA with M1 involvement in the REVASCAT trial, where only patients with proximal M1-MCA with or without concomitant occlusion of the ICA enrolled in the study [1]. The number of tandem occlusions in the MR CLEAN trial was 59/233 (25.3%) [2]. The tandem occlusions were caused either by atherosclerosis (5 cases) or dissection (3 cases) in the patient group. These etiologies are in line with the study by Matsubara et al. [8]. Internal carotid artery dissection as
Table 1 Demographic findings, NIHSS scores, occlusion sites, etiology, stent placement and mRS scores of the patients.
Case Case Case Case Case Case Case Case
1 2 3 4 5 6 7 8
Age
Sex
NIHSS
Intracranial occlusion site
Etiology
Stenting
mRS on 90th day
56 58 66 23 53 74 60 66
F M M M M M M M
21 24 14 11 19 25 15 19
M1 A1 + M1 A1 + M1 M1 M1 M1 + A1 M1 M1
High grade stenosis High grade stenosis High grade stenosis Dissection Dissection Dissection and AF High grade stenosis High grade stenosis
Yes Yes Yes Yes – – Yes Yes
1 6 2 1 3 4 2 2
Please cite this article in press as: Akpınar S, Gelener P. Endovascular treatment of acute tandem occlusion strokes and stenting first experience. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.09.010
S. Akpınar, P. Gelener / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
3
Fig. 3. Digital subtraction image of the right middle cerebral artery (M1 segment) tandem occlusion identified after the passage through the high grade ICA stenosis.
Fig. 2. Digital subtraction image of the restored flow after thrombectomy. The carotid wall stent is shown, implemented at the occlusion site.
a cause of tandem occlusion strokes among young patients is frequent. The decision to perform intracranial revascularization first or cervical revascularization still remains controversial. However, there are increasing reports in favour of the stent-first approach in endovascular treatment of tandem occlusions [4,9,10]. All of the patients in the present study underwent SAT and emergency ICA stent implantation was applied to 6 out of 8 patients using the stent-first approach (Fig. 3). Ipsilateral carotid stenting was performed in 6 out of 70 (8.5%) patients in this study whereas in the REVASCAT trial, this was 9 out of 98 patients (8.7%) [1]. In the MR CLEAN trial, 30 out of 233 patients (13%) underwent acute cervical carotid stenting after intra-arterial treatment [2]. Although both approaches seem to be feasible in terms of recanalization rates and clinical outcomes, Maurer et al. reported the advantage of opening the proximal occlusion first [10]. The advantages of proximal ICA stenting are that it stabilizes the stenotic ICA surface and increases the blood flow to the distal cerebral vessels, which may be effective on the salvage of penumbra [8,11]. According to Kwak et al., good outcomes after emergency carotid artery stenting were also attributed to the patient’s
younger age, lower initial NIHSS scores and TICI grades 2b or 3 [12]. Spontaneous reperfusion of the intracranial vessel occlusion after stenting of the proximal ICA has been stated in some studies (Stampfl et al.). In the present study, none of the patients showed spontaneous reperfusion in the CAS group [13]. In patients with dissection on whom only SAT was performed, dissected segment was not progressive without causing flow disturbance during control runs. However, in the first dissection case, flow disturbance was observed with irregularity at the luminal site, hence stenting was applied to prevent distal embolization. Some reports claim that proximal stenting of the cervical carotid before treatment of the intracranial occlusion may delay the distal recanalization time [11]. According to Ribo et al., every 30 min delay in reperfusion is associated with a 5% relative reduction in good clinical outcome [14]. Lockau et al. and Stampfl et al. reported that stenting-first caused a 20 min delay in reperfusion time compared to the thrombectomy first group, which was attributed to better mRS scores [4,13]. In patient group in the present study, the longest CAS session was 15 min, which did not delay the distal recanalization time. Seven out of 8 patients (87.5%) had high recanalization rates (TICI 2b and 3). This rate was 81% in Matsubara’s, 63% in Papanagiotou’s, 63% in Stampfl and 75% in Malik’s case series [4,11,13,15].
Please cite this article in press as: Akpınar S, Gelener P. Endovascular treatment of acute tandem occlusion strokes and stenting first experience. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.09.010
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S. Akpınar, P. Gelener / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Periprocedural complications occurred in 2 of the patients which were thrombosis of the stent and reperfusion haemorrhage. Despite the loading dose of clopidogrel before stent replacement, in-stent thrombosis was noticed in one of the patients. This patient was admitted to re-intervention and TICI 3 was achieved again. A higher risk of intracranial haemorrhage is reported in tandem occlusions after recanalization [10]. One of our patients died secondary to symptomatic parenchymal haemorrhage as a result of reperfusion syndrome. In one of the cases, after CAS, insufficient opening of the stent caused catching of the Solitaire stent retriever to the strands of the carotid wallstent. This was handled by upward pushing of the smaller size guiding catheter as there was no distal access catheter available at that time. A similar situation was also reported in another study by H. Lockau et al. [4]. The rate of major complications is reported to range from 13% to 20% in the literature. In the present study, this rate was 1/8 (12.5%) in the patient group as a result of reperfusion syndrome. Mortality rate in this study was 1/8 (12.5%) which was stated as 10% in Lescher, 16.6% in Stampfl and 23.4% in Malik et al.’s studies [11,13,15]. Five out of eight tandem occlusion patients achieved good clinical outcomes with mRS 2 on day 90. Of the stent first group, 5 out of 6 patients had mRS 2 on day 90. Other studies have also reported mRS 2 at 90th day, ranging from 18% to 100% [8,13]. This study is limited due to the small sample size and single centre experience, which is insufficient for statistical analysis. However, endovascular intervention benefited 7 out of the 8 patients with tandem strokes.
5. Conclusion According to the present study, SAT with or without a stent-first approach resulted in a successful revascularization rate with favourable outcomes in acute stroke patients with tandem occlusions. As a result, this study encourages non inferiority of proximal stenting and distal thrombectomy for acute tandem strokes in extracranial high-grade ICA stenosis or dissection. No funding or other sources of support was received for this study. The sponsor had no role in the design or conduct of this research. We have no conflict of interest.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.jocn.2017.09.010. References [1] Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Eng J Med 2015;372(24):2296–306. [2] Berkhemer OA, Fransen PS, Beumer D, Van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372(1):11–20. [3] Cohen JE, Gomori JM, Rajz G, Itshayek E, Eichel R, Leker RR. Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandemocclusive disease. J Neurointerv Surg 2014;7(6):412–7. [4] Lockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, et al. Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 2015;57:589–98. [5] Puri AS, Kühn AL, Kwon HJ, Khan M, Hou SY, Lin E, et al. Endovascular treatment of tandem vascular occlusions in acute ischemic stroke. J Neurointerv Surg 2015;7(3):158–63. [6] Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta analysis of individual patient data from five randomised trials. Lancet 2016;2387(10029):1723–31. [7] Kappelhof M, Marquering HA, Berkhemer OA, Majoie CB. Intra-arterial treatment of patients with acute ischemic stroke and internal carotid artery occlusion. A literature review. J Neurointerv Surg 2015;7:8–15. [8] Matsubara N, Miyachi S, Tsukamoto N, Kojima T, Izumi T, Haraguchi K, et al. Endovascular intervention for acute cervical carotid artery occlusion. Acta Neurochir 2013;155:1115–23. [9] Gao F, Joyce Lo W, Sun X, Xu X, Miao Z. Combined use of stent angioplasty and mechanical thrombectomy for acute tandem internal carotid and middle cerebral artery occlusion. Neuroradiol J 2015;28(3):316–21. [10] Maurer CJ, Joachimski F, Berlis A. Two in one: endovascular treatment of acute tandem occlusions in the anterior circulation. Clin Neuroradiol 2015;25:397–402. [11] Lescher S, Czeppan K, Porto L, Singer OC, Berkefeld J. acute stroke and obstruction of the extracranial carotid artery combined with intracranial tandem occlusion: results of interventional revascularization. Cardiovasc Intervent Radiol 2015;38:304–13. [12] Kwak HS, Hwang SB, Jn GY, Hippe DS, Chun GH. Predictors of functional outcome after emergency carotid artery stenting and intra-arterial thrombolysis for treatment of acute stroke associated with obstruction of the proximal internal carotid artery and tandem downstream occlusion. AJNR Am J Neuroradiol 2013;34:841–6. [13] Stampfl S, Ringleb PA, Möhlenbruch M, Hametner C, Herweh C, Pham M, et al. Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 2014;35 (4):741–6. [14] Ribo M, Molina CA, Cobo E, Cerdà N, Tomasello A, Quesada H, et al. Association between time to reperfusion and outcome is primarily driven by the time from imaging to reperfusion. Stroke 2016;47(4):999–1004. [15] Malik AM, Vora NA, Lin R, Zaidi S, Aleu A, Jankowitz B, et al. Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience. Stroke 2011;42:1653–7.
Please cite this article in press as: Akpınar S, Gelener P. Endovascular treatment of acute tandem occlusion strokes and stenting first experience. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.09.010
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical note
Endovascular treatment of acute tandem occlusion strokes and stenting first experience Süha Akpınar a, Pınar Gelener b,c,⇑ a
Radiology Department, Near East University Faculty of Medicine, Nicosia, North Cyprus, Mersin 10, Turkey Neurology Department, Kyrenia University Dr. Suat Günsel Faculty of Medicine, North Cyprus, Mersin 10, Turkey c Near East University Faculty of Medicine, Nicosia, North Cyprus, Mersin 10, Turkey b
a r t i c l e
i n f o
Article history: Received 13 March 2017 Accepted 18 September 2017 Available online xxxx Keywords: Tandem strokes Stent first Endovascular treatment
a b s t r a c t This study demonstrates the radiologic and clinical findings, etiologies and intervention strategy in 8 acute ischemic stroke patients with tandem occlusions. The mean age was 57 and mean NIHSS score was 19. Stent-assisted thrombectomy (SAT) was performed on all of the patients. Additionally, 6 patients underwent carotid artery stenting before SAT. Recanalization with TICI 2b was attained in 7/8 patients. The 90th day median mRS was 2 and mortality was 1/8. The etiologies of the tandem occlusions were either extracranial high grade ICA stenosis/occlusion or cervical ICA dissection. When the stent-first approach was applied with distal thrombectomy, high TICI and low mRS scores were obtained. Ó 2017 Elsevier Ltd. All rights reserved.
1. Introduction Acute tandem occlusion is generally defined as concomitant stenosis/occlusions of the cervical ICA and MCA. However, it was defined as terminal ICA with M1-MCA involvement in the REVASCAT trial and ICA occlusion with the involvement of M1-MCA occlusion in the MR CLEAN trial [1,2]. Among acute stroke patients, 10–20% of them have additional occlusions or stenosis of the ipsilateral cervical internal carotid artery [3]. In those patients, the recanalization rate is limited to 5.9% with only intravenous thrombolysis (IVT) [4]. Resultantly, these so-called tandem occlusions are preferably treated with endovascular interventions. There are mainly two endovascular treatment options that have been described. In the proximal to distal approach, the proximal occlusion is recanalized first by either stenting or balloon angioplasty, followed by distal mechanical thrombectomy [5]. In the distal to proximal approach, a stent assisted thrombectomy (SAT) is performed first at the distal MCA and/or ACA occlusion site. There is an increasing amount of data on emergency ICA stenting and intracranial thrombectomy reinforcing the therapeutic value of endovascular interventions in the latest trials [6]. However, the optimal selection of patients and the preferred technique of intervention of this group are still a cause for debate. According to the
⇑ Corresponding author at: Department of Neurology, Kyrenia University Dr. Suat Günsel Faculty of Medicine, North Cyprus, Mersin 10, Turkey. E-mail address: [email protected] (P. Gelener).
latest ESO-Karolinska Stroke Update Conference, acute stenting of the occlusion site has resulted in higher recanalization rates and favourable outcomes [7]. The aim of this study is to evaluate the results of endovascular treatment of acute tandem occlusions in a patient group with the stent-first approach and to discuss the course of intervention, recanalization rates, procedural complications and clinical outcomes in respect to the literature.
2. Materials and methods Clinical presentation, imaging and procedural data of all 70 consecutive patients who were subjected to endovascular treatment for acute ischemic stroke, within a four year period (between 2012 and 2016) were collected retrospectively. The inclusion criteria were: patients admitted within 6 h of symptom onset, exclusion of haemorrhage at plain CT, CT signs of ischemia less than 1/3 of the MCA territory, findings of tandem occlusion of the intracranial MCA and ICA stenosis/occlusion on DSA. The institutional human investigation review board did not exist when the study was initiated. Hence, the principles of the Declaration of Helsinki were followed. National Institutes of Health Stroke Scale (NIHSS) scores were noted at the time of admission. None of the patients received intravenous thrombolysis. Non-contrast CT and CTA (Somatom Sensation 16, Siemens, Germany) were followed by monoplanar DSA (Allura Xper FD20, Philips, Netherlands) guided intervention. General anesthesia was administered on all patients.
https://doi.org/10.1016/j.jocn.2017.09.010 0967-5868/Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Akpınar S, Gelener P. Endovascular treatment of acute tandem occlusion strokes and stenting first experience. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.09.010
2
S. Akpınar, P. Gelener / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
All CTA findings were evaluated by a single European board certified neuroradiologist with 5 years’ experience on stroke imaging. An 8 Fr introducer was usually placed into the puncture site for an anterior circulation stroke, followed by a Simmons 2 catheter (Stryker Neurovascular, USA) or vertebral catheter 100/125 cm (Cook, USA) to engage the supra-aortic arteries. A Terumo stiff guidewire (Terumo, Tokyo, Japan) was used to launch the 8 Fr Corail balloon-guiding catheter (Balt, France) to the main arteries. According to the initial DSA findings, endovascular proximal ICA stenting was planned before the thrombectomy procedure. The ICA stent was launched without a protection device. In cases with insufficient stent opening, post-stenting balloon angioplasty by using a 6 mm 40 mm balloon following ICA stenting was performed. The Solitaire (FR Covidien/ev3 Inc., Irvine, USA) stent retriever was used only for the SAT. Wallstent (Boston Scientific, USA) was used for internal carotid artery stenting (CAS). Systemic anticoagulation was supplied by 5000 IU of heparin to patients on whom primary stenting was performed. They also received the loading dose of clopidogrel after stent implantation. Nimodipine infusion was additionally used to prevent cerebral vasospasm. Reperfusion success was rated on the basis of the thrombolysis in the cerebral infarction (TICI) scale (successful reperfusion defined as TICI scores 2b and 3). The modified Rankin scale (mRS) was documented 3 months after stroke onset. Good clinical outcomes were defined as mRS 0–2.
3. Results Overall, 70 patients underwent endovascular treatment. Eight (11.4%) of them (2 female, 6 male) had tandem occlusions. The mean age was 57 with a range from 23 and 74 years and the median NIHSS at admission was 19 (range from 11 to 25 points) (Table 1). Initial CTAs revealed a high-grade stenosis/occlusion of the cervical ICA in all patients. DSA showed high grade extracranial carotid stenosis in 5 patients (Fig. 1) and extracranial dissection in 3 patients. Intracranial occlusion sites documented by DSA were MCA-M1 in all patients (Fig. 3) and additional ACA-A1 occlusion was observed in 3 patients (Table 1). All of the 8 patients went through SAT. Carotid artery stenting was performed in 6 out of the 8 patients with the stenting-first (proximal to distal) approach before SAT. These patients included 5 with high grade ICA stenosis and 1 with cervical ICA dissection (Fig. 2) (Table 1). Resultantly, successful reperfusion (TICI 2b/3) was achieved in 7/8 patients. The duration of the CAS session was between 7 and 15 min. Procedural complications were; stent re-occlusion and parenchymal haemorrhage type 2. At discharge, 7/8 patients had a favourable to moderate outcome (mRS 0–3). Median mRS at discharge was 2. Only 1 out of the 8 patients died during his initial hospital stay. After 3 months, the median mRS remained at 2 (range 1–6). Of these, minimal or no disability (mRS between 0 and 1) was found in 2 patients and 3
Fig. 1. Digital subtraction image of the right internal carotid artery occlusion showing no flow to the distal internal carotid artery and distal vessels.
patients had a favourable clinical outcome (mRS 2). Two patients had moderate to severe disability with an mRS of 3 and 4 and one patient died (Table 1). 4. Discussion Of the 70 patients who underwent endovascular treatment 8 (11.4%) of them had tandem occlusions in the patient group studied. Three of them had additional ACA occlusion. The number of tandem occlusions was 26/102 (25.5%) terminal ICA with M1 involvement in the REVASCAT trial, where only patients with proximal M1-MCA with or without concomitant occlusion of the ICA enrolled in the study [1]. The number of tandem occlusions in the MR CLEAN trial was 59/233 (25.3%) [2]. The tandem occlusions were caused either by atherosclerosis (5 cases) or dissection (3 cases) in the patient group. These etiologies are in line with the study by Matsubara et al. [8]. Internal carotid artery dissection as
Table 1 Demographic findings, NIHSS scores, occlusion sites, etiology, stent placement and mRS scores of the patients.
Case Case Case Case Case Case Case Case
1 2 3 4 5 6 7 8
Age
Sex
NIHSS
Intracranial occlusion site
Etiology
Stenting
mRS on 90th day
56 58 66 23 53 74 60 66
F M M M M M M M
21 24 14 11 19 25 15 19
M1 A1 + M1 A1 + M1 M1 M1 M1 + A1 M1 M1
High grade stenosis High grade stenosis High grade stenosis Dissection Dissection Dissection and AF High grade stenosis High grade stenosis
Yes Yes Yes Yes – – Yes Yes
1 6 2 1 3 4 2 2
Please cite this article in press as: Akpınar S, Gelener P. Endovascular treatment of acute tandem occlusion strokes and stenting first experience. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.09.010
S. Akpınar, P. Gelener / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
3
Fig. 3. Digital subtraction image of the right middle cerebral artery (M1 segment) tandem occlusion identified after the passage through the high grade ICA stenosis.
Fig. 2. Digital subtraction image of the restored flow after thrombectomy. The carotid wall stent is shown, implemented at the occlusion site.
a cause of tandem occlusion strokes among young patients is frequent. The decision to perform intracranial revascularization first or cervical revascularization still remains controversial. However, there are increasing reports in favour of the stent-first approach in endovascular treatment of tandem occlusions [4,9,10]. All of the patients in the present study underwent SAT and emergency ICA stent implantation was applied to 6 out of 8 patients using the stent-first approach (Fig. 3). Ipsilateral carotid stenting was performed in 6 out of 70 (8.5%) patients in this study whereas in the REVASCAT trial, this was 9 out of 98 patients (8.7%) [1]. In the MR CLEAN trial, 30 out of 233 patients (13%) underwent acute cervical carotid stenting after intra-arterial treatment [2]. Although both approaches seem to be feasible in terms of recanalization rates and clinical outcomes, Maurer et al. reported the advantage of opening the proximal occlusion first [10]. The advantages of proximal ICA stenting are that it stabilizes the stenotic ICA surface and increases the blood flow to the distal cerebral vessels, which may be effective on the salvage of penumbra [8,11]. According to Kwak et al., good outcomes after emergency carotid artery stenting were also attributed to the patient’s
younger age, lower initial NIHSS scores and TICI grades 2b or 3 [12]. Spontaneous reperfusion of the intracranial vessel occlusion after stenting of the proximal ICA has been stated in some studies (Stampfl et al.). In the present study, none of the patients showed spontaneous reperfusion in the CAS group [13]. In patients with dissection on whom only SAT was performed, dissected segment was not progressive without causing flow disturbance during control runs. However, in the first dissection case, flow disturbance was observed with irregularity at the luminal site, hence stenting was applied to prevent distal embolization. Some reports claim that proximal stenting of the cervical carotid before treatment of the intracranial occlusion may delay the distal recanalization time [11]. According to Ribo et al., every 30 min delay in reperfusion is associated with a 5% relative reduction in good clinical outcome [14]. Lockau et al. and Stampfl et al. reported that stenting-first caused a 20 min delay in reperfusion time compared to the thrombectomy first group, which was attributed to better mRS scores [4,13]. In patient group in the present study, the longest CAS session was 15 min, which did not delay the distal recanalization time. Seven out of 8 patients (87.5%) had high recanalization rates (TICI 2b and 3). This rate was 81% in Matsubara’s, 63% in Papanagiotou’s, 63% in Stampfl and 75% in Malik’s case series [4,11,13,15].
Please cite this article in press as: Akpınar S, Gelener P. Endovascular treatment of acute tandem occlusion strokes and stenting first experience. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.09.010
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S. Akpınar, P. Gelener / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Periprocedural complications occurred in 2 of the patients which were thrombosis of the stent and reperfusion haemorrhage. Despite the loading dose of clopidogrel before stent replacement, in-stent thrombosis was noticed in one of the patients. This patient was admitted to re-intervention and TICI 3 was achieved again. A higher risk of intracranial haemorrhage is reported in tandem occlusions after recanalization [10]. One of our patients died secondary to symptomatic parenchymal haemorrhage as a result of reperfusion syndrome. In one of the cases, after CAS, insufficient opening of the stent caused catching of the Solitaire stent retriever to the strands of the carotid wallstent. This was handled by upward pushing of the smaller size guiding catheter as there was no distal access catheter available at that time. A similar situation was also reported in another study by H. Lockau et al. [4]. The rate of major complications is reported to range from 13% to 20% in the literature. In the present study, this rate was 1/8 (12.5%) in the patient group as a result of reperfusion syndrome. Mortality rate in this study was 1/8 (12.5%) which was stated as 10% in Lescher, 16.6% in Stampfl and 23.4% in Malik et al.’s studies [11,13,15]. Five out of eight tandem occlusion patients achieved good clinical outcomes with mRS 2 on day 90. Of the stent first group, 5 out of 6 patients had mRS 2 on day 90. Other studies have also reported mRS 2 at 90th day, ranging from 18% to 100% [8,13]. This study is limited due to the small sample size and single centre experience, which is insufficient for statistical analysis. However, endovascular intervention benefited 7 out of the 8 patients with tandem strokes.
5. Conclusion According to the present study, SAT with or without a stent-first approach resulted in a successful revascularization rate with favourable outcomes in acute stroke patients with tandem occlusions. As a result, this study encourages non inferiority of proximal stenting and distal thrombectomy for acute tandem strokes in extracranial high-grade ICA stenosis or dissection. No funding or other sources of support was received for this study. The sponsor had no role in the design or conduct of this research. We have no conflict of interest.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.jocn.2017.09.010. References [1] Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Eng J Med 2015;372(24):2296–306. [2] Berkhemer OA, Fransen PS, Beumer D, Van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372(1):11–20. [3] Cohen JE, Gomori JM, Rajz G, Itshayek E, Eichel R, Leker RR. Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandemocclusive disease. J Neurointerv Surg 2014;7(6):412–7. [4] Lockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, et al. Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 2015;57:589–98. [5] Puri AS, Kühn AL, Kwon HJ, Khan M, Hou SY, Lin E, et al. Endovascular treatment of tandem vascular occlusions in acute ischemic stroke. J Neurointerv Surg 2015;7(3):158–63. [6] Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta analysis of individual patient data from five randomised trials. Lancet 2016;2387(10029):1723–31. [7] Kappelhof M, Marquering HA, Berkhemer OA, Majoie CB. Intra-arterial treatment of patients with acute ischemic stroke and internal carotid artery occlusion. A literature review. J Neurointerv Surg 2015;7:8–15. [8] Matsubara N, Miyachi S, Tsukamoto N, Kojima T, Izumi T, Haraguchi K, et al. Endovascular intervention for acute cervical carotid artery occlusion. Acta Neurochir 2013;155:1115–23. [9] Gao F, Joyce Lo W, Sun X, Xu X, Miao Z. Combined use of stent angioplasty and mechanical thrombectomy for acute tandem internal carotid and middle cerebral artery occlusion. Neuroradiol J 2015;28(3):316–21. [10] Maurer CJ, Joachimski F, Berlis A. Two in one: endovascular treatment of acute tandem occlusions in the anterior circulation. Clin Neuroradiol 2015;25:397–402. [11] Lescher S, Czeppan K, Porto L, Singer OC, Berkefeld J. acute stroke and obstruction of the extracranial carotid artery combined with intracranial tandem occlusion: results of interventional revascularization. Cardiovasc Intervent Radiol 2015;38:304–13. [12] Kwak HS, Hwang SB, Jn GY, Hippe DS, Chun GH. Predictors of functional outcome after emergency carotid artery stenting and intra-arterial thrombolysis for treatment of acute stroke associated with obstruction of the proximal internal carotid artery and tandem downstream occlusion. AJNR Am J Neuroradiol 2013;34:841–6. [13] Stampfl S, Ringleb PA, Möhlenbruch M, Hametner C, Herweh C, Pham M, et al. Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 2014;35 (4):741–6. [14] Ribo M, Molina CA, Cobo E, Cerdà N, Tomasello A, Quesada H, et al. Association between time to reperfusion and outcome is primarily driven by the time from imaging to reperfusion. Stroke 2016;47(4):999–1004. [15] Malik AM, Vora NA, Lin R, Zaidi S, Aleu A, Jankowitz B, et al. Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience. Stroke 2011;42:1653–7.
Please cite this article in press as: Akpınar S, Gelener P. Endovascular treatment of acute tandem occlusion strokes and stenting first experience. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.09.010