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.

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

When your doctor suggests this have them guarantee no complications.

Problems to consider:

You might want to ask your doctor about this?

New ischemic brain lesions on diffusion-weighted MRI after treatment were found in 51% of cases after stenting.  Link here

 

1.  Talk to your doctor about why you would want to put inflexible metal stents in flexible arteries.

2. You might want to prevent stent placement complications per European Society of Cardiology

A - Minor complications

• Carotid artery spasm

• Sustained hypotension / bradycardia

• Carotid artery dissection

• Contrast encephalopathy (very rare)

• Minor embolic neurological events (TIAs)

B - Major complications

• Major embolic stroke

• Intracranial hemorrhage

• Hyperperfusion syndrome

• Carotid perforation (very rare)

• Acute stent thrombosis (very rare)

• Complications at the site of the vascular access

Tandem lesion (or tandem occlusion) is a term used in cerebrovascular imaging and intervention to refer to the simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery¹.

  The latest here:

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

1. http://orcid.org/0000-0002-3245-917XFrancesco Diana1,
2. Michele Romoli2,
3. Giada Toccaceli3,
4. Aymeric Rouchaud4,5,
5. Charbel Mounayer4,5,
6. Daniele Giuseppe Romano1,
7. Francesco Di Salle6,
8. Paolo Missori7,
9. Andrea Zini8,
10. http://orcid.org/0000-0002-6702-7924Diana Aguiar de Sousa9,
11. http://orcid.org/0000-0002-3920-8517Simone Peschillo10,11

1. Correspondence to Dr Francesco Diana, Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d’Aragona', 84131 Salerno, Campania, Italy; francesco.diana.md@gmail.com

Abstract

Background Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear.

Objective To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion.

Methods Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0–2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b–3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling.

Results Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors.

Conclusions In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.

http://dx.doi.org/10.1136/neurintsurg-2022-018683