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Original Research ARTICLE Provisionally accepted The full-text will be published soon. Notify me

Front. Neurol. | doi: 10.3389/fneur.2018.00940

Functional Outcome And Safety Of Intracranial Thrombectomy After Emergent Extracranial Stenting In Acute Ischemic Stroke Due To Tandem Occlusions

 Philipp Bücke1*, Marta Aguilar Pérez2, Muhammad AlMatter2, Victoria Hellstern2, Hansjörg Bäzner1 and  Hans Henkes2
  • 1Neurologische Klinik, Klinikum Stuttgart, Germany
  • 2Klinik für Neuroradiologie, Klinikum Stuttgart, Germany

Background and Purpose: Various endovascular approaches to treat acute ischemic stroke caused by extra- intracranial tandem occlusions (TO) exist: percutaneous transluminal angioplasty with or without emergent extracranial carotid stenting (ECS) due to high-grade stenosis preceded or followed by intracranial mechanical and/or aspiration thrombectomy (MT). Which treatment strategy to use is still a matter of debate.
Methods: From our ongoing prospective stroke registry we retrospectively analyzed 1071 patients with anterior circulation stroke getting endovascular treatment within six hours of symptom onset. ECS prior to intracranial MT for TO (n=222) was compared to MT as standard of care (control group; acute intracranial vessel occlusion without concomitant ipsilateral ICA-occlusion or high-grade stenosis [C; n=849]). Good functional outcome (mRS ≤ 2 at 3 months), mortality rates, frequencies of symptomatic intracranial hemorrhage (sICH) and successful recanalization (Thrombolysis in Cerebral Infarction Score [TICI] 2b or 3) were assessed. In subgroup analyses we tried to detect possible influences of stroke etiology, dual inhibition of platelet aggregation (IPA; clopidogrel [CLO]: n=83; ticagrelor [TIC]: n=137; in combination with Aspirin) and intravenous thrombolysis (IVT).
Results: Functional outcome was superior in TO (mRS 0-2: 44.6%) when compared with controls (36.0%; (OR [95% CI]: 3.49 [1.59-7.67];p=0.002). There was no difference in all-cause mortality at three months (TO: 21.6%; C: 27.7%; 0.78 [0.47-1.29;p=0.324), in-hospital mortality (0.76 [0.45-1.30; p=0.324), sICH (TO: 3.2%; C: 5.0%; 0.70 [0.30-1.59;p=0.389) and TICI 2b/3 (TO: 89.1%; C: 88.3%; p=0.813). In subgroup-analysis, TIC and CLO did not differ in functional outcome (TIC: 45.3%; CLO: 44.6%; 1.04 [0.51-2.09]; p=0.920) and mortality rates (all-cause mortality: TIC: 23.4%; CLO: 16.9%; 0.75 [0.27-2.13]; p=0.594). sICH was more frequent in TIC (n=7 [5.1%]) versus CLO (n=0; p=0.048).
Conclusion: In our pre-selected cohort, ECS prior to intracranial MT in TO allowed for a good functional outcome that was superior compared to a control population. Mortality rates did not differ. Despite a dual IPA in TO, there was no increase in sICH. CLO and TIC for dual IPA did not differ in terms out outcome and mortality rates. A significant increase in sICH was observed after initial loading with TIC.

Keywords: tandem occlusions, acute ischaemic stroke (AIS), Endovascular Therapy, Thrombectomy, Extracranial stenosis, functional outcome, Inhibition of platelet aggregation

Received: 25 Aug 2018; Accepted: 17 Oct 2018.

Edited by:

Daniel Behme, Universitätsmedizin Göttingen, Germany

Reviewed by:

Benjamin Friedrich, Klinikum rechts der Isar, Technische Universität München, Germany
Kai Kallenberg, Asklepios Kliniken Schildautal, Germany  

Copyright: © 2018 Bücke, Aguilar Pérez, AlMatter, Hellstern, Bäzner and Henkes. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: MD. Philipp Bücke, Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany,