STROKE IN PATIENTS WITH TANDEM LESIONS: WHAT IS THE CLINICAL SIGNIFICANCE AND SAFETY OF EMERGENT REVASCULARIZATION OF THE EXTRACRANIAL INTERNAL CAROTID ARTERY?
DOI:
https://doi.org/10.48750/acv.52Keywords:
Acute ischemic stroke, Tandem occlusion, Emergent carotid stenting, Angioplasty-assisted mechanical thrombectomyAbstract
Acute ischemic stroke as a result of tandem occlusion, is defined as a combination of internal cervical carotid artery (ICA) stenosis with synchronous intracranial thrombus and accounts for about 10–20% of all strokes. Nevertheless, their approach remains controversial and variable according to the center's experience.
The aim of any stroke treatment must be to successfully revascularize as soon as possible. In tandem occlusion, the primary cause of symptoms and clinical outcome is thrombus in the intracranial arteries rather than the occlusion of the cervical ICA. Today, standard of care for such intracranial lesions is mechanical thrombectomy with stent retriever combined with thrombolysis. However, distal access is hampered by the ICA stenosis/occlusion.
The objective of this review was to evaluate the clinical importance and risks associated with emergent revascularization of the internal carotid artery using angioplasty and stenting in tandem occlusions.
With this purpose a revision of existing literature was performed using Medline database.
Surpassing an extra-cranial ACI lesion with subsequent stent placement seems to have a high recanalization rate, but it is time-consuming, thus delaying the time for distal recanalization and potentially conditioning less favorable neurological outcomes.
In the literature, there is no evidence of patient outcome improvement with emergent stent placement in regard to intracranial recanalization (Thrombolysis in Cerebral Infarction≥2b), clinical outcome (modified Rankin Scale ≤2) and mortality rate at 90 days. Additionally, emergent stent placement exposes the patient to the additional risk of stroke associated with the procedure and intracranial hemorrhage.
We therefore conclude that currently, there is no evidence in the literature to support emergent carotid stenting in stroke due to tandem occlusions.
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References
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mechanical thrombectomy without urgent stenting may be a
better option in acute tandem occlusions. Interv Neuroradiol.
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carotid artery and intracranial stent-based thrombectomy
in acute tandem occlusive disease: technical considerations. J
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Kabbasch C, et al. Mechanical thrombectomy in tandem occlusion:
procedural considerations and clinical results. Neuroradiology.
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17. Ozdemir O, Bussiere M, Leung A, Gulka I, Lee D, Chan R, et al. Intra-
-arterial thrombolysis of occluded middle cerebral artery by use
of collateral pathways in patients with tandem cervical carotid
artery/middle cerebral artery occlusion. AJNR Am J Neuroradiol.
2008;29(8):1596–600.
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artery stenting in the early period after carotid-related cerebral
ischemia? J Cardiovasc Surg (Torino). 2015;56(6):853–7.
19. Dorado L, Castano C, Millan M, Aleu A, de la Ossa NP, Gomis M, et al.
Hemorrhagic risk of emergent endovascular treatment plus stenting
in patients with acute ischemic stroke. J Stroke Cerebrovasc
Dis. 2013;22(8):1326–31.
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of neurointerventional emergency treatment of extra- or
intracranial tandem occlusions in acute major stroke: antegrade
approach with wallstent and solitaire stent retriever. Clin Neuroradiol.
2013;23(3):207–15.
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Disease: 2017 Clinical Practice Guidelines of the European Society
for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017.
22. Fugate JE, Klunder AM, Kallmes DF. What is meant by "TICI"? AJNR
Am J Neuroradiol. 2013;34(9):1792–7.
23. 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(2):304–13.
24. Fahed R, Redjem H, Blanc R, Labreuche J, Robert T, Ciccio G, et
al. Endovascular Management of Acute Ischemic Strokes with
Tandem Occlusions. Cerebrovasc Dis. 2016;41(5-6):298–305.
25. Soize S, Kadziolka K, Estrade L, Serre I, Barbe C, Pierot L. Outcome
after mechanical thrombectomy using a stent retriever
under conscious sedation: comparison between tandem
and single occlusion of the anterior circulation. J Neuroradiol.
2014;41(2):136–42.
26. Grigoryan M, Haussen DC, Hassan AE, Lima A, Grossberg J, Rebello
LC, et al. Endovascular Treatment of Acute Ischemic Stroke Due
to Tandem Occlusions: Large Multicenter Series and Systematic
Review. Cerebrovasc Dis. 2016;41(5-6):306–12.
27. Heck DV, Brown MD. Carotid stenting and intracranial thrombectomy
for treatment of acute stroke due to tandem occlusions
with aggressive antiplatelet therapy may be associated with a
high incidence of intracranial hemorrhage. J Neurointerv Surg.
2015;7(3):170–5.
28. Steglich-Arnholm H, Holtmannspotter M, Kondziella D, Wagner
A, Stavngaard T, Cronqvist ME, et al. Thrombectomy assisted by
carotid stenting in acute ischemic stroke management: benefits
and harms. J Neurol. 2015;262(12):2668–75.
29. Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D,
et al. Randomised double-blind placebo-controlled trial of thrombolytic
therapy with intravenous alteplase in acute ischaemic
stroke (ECASS II). Second European-Australasian Acute Stroke
Study Investigators. Lancet. 1998;352(9136):1245–51.
30. Dababneh H, Bashir A, Hussain M, Guerrero WR, Morgan W, Khanna
AY, et al. Endovascular treatment of tandem internal carotid
and middle cerebral artery occlusions. J Vasc Interv Neurol.
2014;7(4):26–31.
31. Maurer CJ, Joachimski F, Berlis A. Two in One: Endovascular Treatment
of Acute Tandem Occlusions in the Anterior Circulation. Clin
Neuroradiol. 2015;25(4):397–402.
32. Mbabuike N, Gassie K, Brown B, Miller DA, Tawk RG. Revascularization
of tandem occlusions in acute ischemic stroke: review of the
literature and illustrative case. Neurosurg Focus. 2017;42(4):E15.
Programa Nacional para as Doenças Cérebro-cardiovasculares;
Ferreira, R.C., Neves, R.C., Rodrigues, V.; Direção Geral de Saúde;
Lisboa, 2013;
2. Stampfl S, Ringleb PA, Mohlenbruch 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.
3. National Institute of Neurological D, Stroke rt PASSG. Tissue
plasminogen activator for acute ischemic stroke. N Engl J Med.
1995;333(24):1581–7.
4. Jauch EC, Saver JL, Adams HP, Jr., Bruno A, Connors JJ, Demaerschalk
BM, et al. Guidelines for the early management of patients
with acute ischemic stroke: a guideline for healthcare professionals
from the American Heart Association/American Stroke Association.
Stroke. 2013;44(3):870–947.
5. Christou I, Felberg RA, Demchuk AM, Burgin WS, Malkoff M, Grotta
JC, et al. Intravenous tissue plasminogen activator and flow
improvement in acute ischemic stroke patients with internal
carotid artery occlusion. J Neuroimaging. 2002;12(2):119–23.
6. 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.
7. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi
N, et al. Endovascular therapy for ischemic stroke with perfusion-
-imaging selection. N Engl J Med. 2015;372(11):1009–18.
8. 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;387(10029):1723–31.
9. 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 Engl J Med. 2015;372(24):2296–306.
10. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al.
Stent-retriever thrombectomy after intravenous t-PA vs. t-PA
alone in stroke. N Engl J Med. 2015;372(24):2285–95.
11. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al.
2015 American Heart Association/American Stroke Association
Focused Update of the 2013 Guidelines for the Early Management
of Patients With Acute Ischemic Stroke Regarding Endovascular
Treatment: A Guideline for Healthcare Professionals From
the American Heart Association/American Stroke Association.
Stroke. 2015;46(10):3020–35.
12. Akpinar CK, Gurkas E, Aytac E. Carotid angioplasty-assisted
mechanical thrombectomy without urgent stenting may be a
better option in acute tandem occlusions. Interv Neuroradiol.
2017:1591019917701113.
13. Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker
GA, et al. Trevo versus Merci retrievers for thrombectomy revascularisation
of large vessel occlusions in acute ischaemic stroke
(TREVO 2): a randomised trial. Lancet. 2012;380(9849):1231–40.
14. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira
RG, et al. Solitaire flow restoration device versus the Merci
Retriever in patients with acute ischaemic stroke (SWIFT):
a randomised, parallel-group, non-inferiority trial. Lancet.
2012;380(9849):1241–9.
15. Cohen JE, Gomori M, Rajz G, Moscovici S, Leker RR, Rosenberg S,
et al. Emergent stent-assisted angioplasty of extracranial internal
carotid artery and intracranial stent-based thrombectomy
in acute tandem occlusive disease: technical considerations. J
Neurointerv Surg. 2013;5(5):440–6.
16. 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(6):589–98.
17. Ozdemir O, Bussiere M, Leung A, Gulka I, Lee D, Chan R, et al. Intra-
-arterial thrombolysis of occluded middle cerebral artery by use
of collateral pathways in patients with tandem cervical carotid
artery/middle cerebral artery occlusion. AJNR Am J Neuroradiol.
2008;29(8):1596–600.
18. Rantner B. How safe are carotid endarterectomy and carotid
artery stenting in the early period after carotid-related cerebral
ischemia? J Cardiovasc Surg (Torino). 2015;56(6):853–7.
19. Dorado L, Castano C, Millan M, Aleu A, de la Ossa NP, Gomis M, et al.
Hemorrhagic risk of emergent endovascular treatment plus stenting
in patients with acute ischemic stroke. J Stroke Cerebrovasc
Dis. 2013;22(8):1326–31.
20. Mpotsaris A, Bussmeyer M, Buchner H, Weber W. Clinical outcome
of neurointerventional emergency treatment of extra- or
intracranial tandem occlusions in acute major stroke: antegrade
approach with wallstent and solitaire stent retriever. Clin Neuroradiol.
2013;23(3):207–15.
21. Writing G, Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, et
al. Management of Atherosclerotic Carotid and Vertebral Artery
Disease: 2017 Clinical Practice Guidelines of the European Society
for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017.
22. Fugate JE, Klunder AM, Kallmes DF. What is meant by "TICI"? AJNR
Am J Neuroradiol. 2013;34(9):1792–7.
23. 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(2):304–13.
24. Fahed R, Redjem H, Blanc R, Labreuche J, Robert T, Ciccio G, et
al. Endovascular Management of Acute Ischemic Strokes with
Tandem Occlusions. Cerebrovasc Dis. 2016;41(5-6):298–305.
25. Soize S, Kadziolka K, Estrade L, Serre I, Barbe C, Pierot L. Outcome
after mechanical thrombectomy using a stent retriever
under conscious sedation: comparison between tandem
and single occlusion of the anterior circulation. J Neuroradiol.
2014;41(2):136–42.
26. Grigoryan M, Haussen DC, Hassan AE, Lima A, Grossberg J, Rebello
LC, et al. Endovascular Treatment of Acute Ischemic Stroke Due
to Tandem Occlusions: Large Multicenter Series and Systematic
Review. Cerebrovasc Dis. 2016;41(5-6):306–12.
27. Heck DV, Brown MD. Carotid stenting and intracranial thrombectomy
for treatment of acute stroke due to tandem occlusions
with aggressive antiplatelet therapy may be associated with a
high incidence of intracranial hemorrhage. J Neurointerv Surg.
2015;7(3):170–5.
28. Steglich-Arnholm H, Holtmannspotter M, Kondziella D, Wagner
A, Stavngaard T, Cronqvist ME, et al. Thrombectomy assisted by
carotid stenting in acute ischemic stroke management: benefits
and harms. J Neurol. 2015;262(12):2668–75.
29. Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D,
et al. Randomised double-blind placebo-controlled trial of thrombolytic
therapy with intravenous alteplase in acute ischaemic
stroke (ECASS II). Second European-Australasian Acute Stroke
Study Investigators. Lancet. 1998;352(9136):1245–51.
30. Dababneh H, Bashir A, Hussain M, Guerrero WR, Morgan W, Khanna
AY, et al. Endovascular treatment of tandem internal carotid
and middle cerebral artery occlusions. J Vasc Interv Neurol.
2014;7(4):26–31.
31. Maurer CJ, Joachimski F, Berlis A. Two in One: Endovascular Treatment
of Acute Tandem Occlusions in the Anterior Circulation. Clin
Neuroradiol. 2015;25(4):397–402.
32. Mbabuike N, Gassie K, Brown B, Miller DA, Tawk RG. Revascularization
of tandem occlusions in acute ischemic stroke: review of the
literature and illustrative case. Neurosurg Focus. 2017;42(4):E15.
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Published
2017-12-30
How to Cite
1.
Coelho A, Lobo M, Gouveia R, Silveira D, Campos J, Augusto R, Coelho N, Semião AC, Pinto E, Canedo A. STROKE IN PATIENTS WITH TANDEM LESIONS: WHAT IS THE CLINICAL SIGNIFICANCE AND SAFETY OF EMERGENT REVASCULARIZATION OF THE EXTRACRANIAL INTERNAL CAROTID ARTERY?. Angiol Cir Vasc [Internet]. 2017 Dec. 30 [cited 2024 Nov. 27];13(4):57-63. Available from: https://acvjournal.com/index.php/acv/article/view/52
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Review Article
