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Front. Neurol. | doi: 10.3389/fneur.2019.00127

Treatment Methods and early neurologic improvement after Endovascular Treatment of Tandem Occlusions in Acute Ischemic Stroke

 Marta Wallocha1*, René Chapot1,  Hannes Nordmeyer1, 2,  Jens Fiehler3,  Ralph Weber4 and Paul C. Stracke1, 3
  • 1Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus Essen, Germany, Germany
  • 2Witten/Herdecke University, Faculty of Health – School of Medicine, Witten, Germany, Germany
  • 3Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, University of Tübingen, Germany
  • 4Department of Neurology, Alfried Krupp Krankenhaus, Essen, Germany., Germany

Background and Purpose: A tandem occlusion of the intracranial circulation and the extracranial carotid artery (ICA) occurs in 10-20% of all strokes based on large vessel occlusion (LVO). The optimal treatment strategy for those patients is unknown. We report our management strategy and the outcome in these patients in a large single-center cohort.
Materials and Methods: We retrospectively analyzed all patients treated by Mechanical Thrombectomy (MT) for an intracranial LVO associated to an occlusion of the extracranial ICA between April 2009 and May 2016. The following data were collected: Recanalization rate (mTICI IIb and III), clinical result including early neurological improvement (ENI, NIHSS score improvement of ≥ 8 points after 24 hours or NIHSS score of 0 or 1 after 3 days) and functional outcome during long term follow up. Secondary endpoints were the patency of the internal carotid artery at 24 hours and the rate of symptomatic hemorrhage. Patient demographics and antiaggregation regimen were recorded as co-variables.
Results: 163/1645 (9.9%) MT patients had a tandem occlusion. All thrombectomy procedures were performed with stent retrievers. PTA without additional placement of a stent was achieved in 14 patients, additional placement of a stent was achieved in 149 patients. The overall rate of mTICI IIB/III recanalization was 91.4%. An early neurological improvement was found in 79 of 163 patients (48.4%), respectively 51% (76/149) and 21% (3/14) in the Stent vs non Stent group. 120/163 patients (73.6 %) had a late favorable outcome (mRS 0-2). The ICA reocclusion rate at 24 hours was respectively 5.4 % (8/149) and 42% (6/14) in the Stent vs non Stent group. The rate of symptomatic hemorrhage was 4.9%.
Younger age (p=0.002) and shorter recanalization times (p=0.017) were associated with good outcome.
Conclusion: Stent-PTA of the ICA in addition to MT with a stent retriever was safe and effective in tandem occlusion of the anterior brain circulation. PTA and MT without stenting in tandem lesions showed a higher early re-occlusion rate and lower rate of early neurological improvement. The technical approach should aim the fastest possible recanalization of the intracranial vessels, either with stenting first or last.

Keywords: Tandem occlusion, Stroke, endovascualar treatment, emergency stenting, Thrombectomy

Received: 09 Aug 2018; Accepted: 30 Jan 2019.

Edited by:

Osama O. Zaidat, St. Vincent Mercy Medical Center, United States

Reviewed by:

Angelos A. Konstas, Massachusetts General Hospital, Harvard Medical School, United States
Foad Abd-Allah, Cairo University, Egypt  

Copyright: © 2019 Wallocha, Chapot, Nordmeyer, Fiehler, Weber and Stracke. 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: Ms. Marta Wallocha, Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus Essen, Germany, Essen, Germany,