Endovascular treatment of acute ischemic stroke patients with tandem lesions: antegrade versus retrograde approach

 So your doctor doesn't know what to do with this type of stroke. Your responsibility is either to not have this stroke or get your doctor to initiate research to solve the problem. Is your doctor competent enough to get research started?

Endovascular treatment of acute ischemic stroke patients with tandem lesions: antegrade versus retrograde approach 

Milagros Galecio-Castillo MD

,

Michael Abraham MD

,

Mudassir Farooqui MD, MPH

,

Ameer E. Hassan DO

,

Afshin A. Divani PhD

,

Mouhammad A. Jumaa MD

,

Marc Ribo MD, PhD

,

Nils Petersen MD

,

Johanna Fifi

 MD

,

Waldo R. Guerrer MD

,

Amer M. Malik MD, MBA

,

James E. Siegler MD

,

Thanh N. Nguyen MD

,

Sunil A. Sheth MD

,

Albert J. Yoo MD, PhD

,

Guillermo Linares MD

,

Nazli Janjua MD

,

Darko Quispe-Orozco MD

,

Abid Qureshi MD

,

Wondwossen G. Tekle MD

,

Asad Ikram MD

,

Syed F. Zaidi MD

,

Cynthia B. Zevallos MD

,

Belen Taborda MD

,

Alex Devarajan BS

,

Linda Zhang BS

,

Mohamad Abdalkader MD

,

Sergio Salazar-Marioni MD

,

Jazba Soomro MD

,

Weston Gordon MD

,

Aaron Rodriguez-Calienes MD

,

Juan Vivanco-Suarez MD

,

Katrina Woolfolk RN

,

Maxim Mokin MD

,

Dileep R. Yavagal MD

, and

Santiago Ortega-Gutierrez MD, MSc

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Publication Date:

29 Dec 2023

Page Range:

1–10

Volume/Issue:

Publish Before Print

DOI link:

https://doi.org/10.3171/2023.10.JNS231702

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• ABSTRACT
• SUPPLEMENTARY MATERIALS

OBJECTIVE

The optimal technique for treating tandem lesions (TLs) with endovascular therapy is debatable. The authors evaluated the functional, safety, and procedural outcomes of different approaches in a multicenter study.

METHODS

Anterior circulation TL patients treated from January 2015 to December 2020 were divided on the basis of antegrade versus retrograde approach and included. The evaluated outcomes were favorable modified Rankin Scale (mRS) score (mRS score 0–2) at 3 months, ordinal shift in mRS score, successful recanalization, excellent recanalization, first-pass effect (FPE), time from groin puncture to successful recanalization, symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

RESULTS

Among 691 patients treated at 16 centers, 286 patients (174 antegrade and 112 retrograde approach patients) with acute stenting were included in the final analysis. There were no significant differences in mRS score 0–2 at 90 days (52.2% vs 50.0%, adjusted odds ratio [aOR] 0.83, 95% CI 0.42–1.56, p = 0.54), favorable shift in 90-day mRS score (aOR 1.03, 95% CI 0.66–1.29, p = 0.11), sICH (4.0% vs 4.5%, aOR 0.64, 95% CI 0.24–1.51, p = 0.45), successful recanalization (89.4% vs 93%, aOR 0.49, 95% CI 0.19–1.28, p = 0.19), excellent recanalization (51.4% vs 58.9%, aOR 0.59, 95% CI 0.40–1.07, p = 0.09), FPE (58.3% vs 69.7%, aOR 0.62, 95% CI 0.44–1.15, p = 0.21), and mortality at 90 days (16.6% vs 14.0%, aOR 0.94, 95% CI 0.35–2.44, p = 0.81) between the groups. The median (interquartile range) groin puncture to recanalization time was significantly longer in the antegrade group (59 [43–90] minutes vs 49 [35–73] minutes, p = 0.036).

CONCLUSIONS

The retrograde approach was associated with faster recanalization times with a similar functional and safety profile when compared with the antegrade approach in patients with acute ischemic stroke with TL.

ABBREVIATIONS

AIS = acute ischemic volume; aOR = adjusted odds ratio; ASPECTS = Alberta Stroke Program Early Computed Tomography Score; ENI = early neurological improvement; EVT = endovascular therapy; FPE = first-pass effect; ICA = internal carotid artery; IQR = interquartile range; IVT = intravenous thrombolysis; LVO = large vessel occlusion; mRS = modified Rankin Scale; mTICI = modified Thrombolysis in Cerebral Infarction; NIHSS = National Institutes of Health Stroke Scale; SEIMLESS = simultaneous extracranial, intracranial management of tandem lesions in stroke; sICH = symptomatic intracranial hemorrhage; TL = tandem lesion.