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Clinical Outcome of Neurointerventional Emergency Treatment of Extra- or Intracranial Tandem Occlusions in Acute Major Stroke: Antegrade Approach With Wallstent and Solitaire Stent Retriever

Klinische Ergebnisse der neurointerventionellen Akutbehandlung extra-/intrakranieller Tandem-Okklusionen im akuten Schlaganfall: Antegrader Zugang und Behandlung mittels Wallstent und Solitaire stent-retriever

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Abstract

Background

Acute large cerebral artery occlusions respond poorly to systemic thrombolysis with recombinant tissue plasminogen activator (rTPA) alone. The value of stent retriever–based mechanical thrombectomy in patients with additional extracranial occlusion of the internal carotid artery (ICA), who require acute a priori extracranial stenting in order to reach the intracranial obstruction site, is not well known. We determined the outcome after emergency revascularization in acute stroke with tandem occlusions of the anterior circulation.

Methods

According to specific inclusion/exclusion criteria, eligible stroke patients with large artery occlusions underwent mechanical recanalization with the Solitaire stent retriever. In case of a tandem occlusion, we performed an acute stenting with the Wallstent before thrombectomy. From October 2009 to March 2011, 50 patients were treated according to this protocol; time frames, clinical data, recanalization rates, and midterm outcome were recorded.

Results

Forty-one patients had a large artery occlusion in the anterior circulation and nine in the posterior circulation. Mechanical recanalization was successful in 35/41 cases (85 %). Six of 41 patients (15 %) died in the acute phase. In 17/41 patients (42 %), thrombectomy was preceded by an emergency stenting in the extracranial portion of the internal carotid artery (ICA). National Institutes of Health Stroke Scale (NIHSS)/modified Rankin Scale (mRS) scores showed significant improvement in both the stenting group and the nonstenting group; there were no significant differences between the groups. At 90 days, 54 % of patients with emergency stenting had a good outcome.

Conclusions

Acute extracranial stenting with the Wallstent combined with intracranial Solitaire-based thrombectomy is safe and may lead to an improvement in neurological outcome in patients with an otherwise poor prognosis under i.v. thrombolysis alone.

Zusammenfassung

Hintergrund

Akute Gefäßverschlüsse der großen hirnversorgenden Arterien haben niedrige Rekanalisierungsraten unter alleiniger systemischer Thrombolyse mit rTPA. Die Effizienz einer stent-retriever basierten, mechanischen Thrombektomie in Patienten mit einem zusätzlichen extrakraniellen Verschluss der A. carotis interna, die zunächst extrakraniell gestentet werden müssen, um einen intrakraniellen Zugang zu ermöglichen, ist wenig untersucht. In der vorliegenden Arbeit wurde das klinische Outcome nach endovaskulärer Rekanalisation im akuten Schlaganfall bei Tandem-Okklusionen der vorderen Zirkulation untersucht.

Methoden

Basierend auf spezifischen Ein- und Ausschluss-Kriterien wurden geeignete Patienten mit Verschlüssen großer hirnversorgender Arterien mittels mechanischer Thrombektomie mit dem Solitaire stent-retriever behandelt. Im Falle einer Tandem-Okklusion wurde eine akute Stentimplantation (Wallstent) vorgeschaltet. Zwischen Oktober 2009 und März 2011 wurden 50 Patienten endovaskulär behandelt. Erfasst wurde neben den klinischen und angiographischen Parametern auch das klinische Outcome nach 90 Tagen.

Ergebnisse

41 Patienten hatten einen Verschluss eines großen hirnversorgenden Gefässes in der vorderen, 9 in der hinteren Zirkulation. Die Rekanalisationsrate betrug in der vorderen Zirkulation 85 % (35/41). 6/41 Patienten (15 %) verstarben in der akuten Phase. In 17/41 Patienten (42 %) war eine vorgeschaltete, akute, Stent-basierte Rekanalisation der extrakraniellen A. carotis interna erforderlich. Die respektiven NIHSS (National Institutes of Stroke Health Scale) und mRS (modifizierte Rankin Skala) Scores verbesserten sich sowohl in der Gruppe der akut gestenteten Patienten, als auch in der Gruppe der nicht gestenteten Patienten; es wurden keine signifikanten Unterschiede zwischen beiden Gruppen beobachtet. Nach 90 Tagen wiesen 54 % der akut gestenteten Patienten ein gutes klinisches Ergebniss auf.

Schlussfolgerungen

Die Kombination eines akuten extrakraniellen Stentings der A. carotis interna verbunden mit einer anschließenden intrakraniellen mechanischen Rekanalisation mittels Solitaire ist technisch sicher und kann zu einer Verbesserung des neurologischen Ergebnisses bei Patienten führen, die unter alleiniger systemischer Thrombolyse eine eingeschränkte Prognose aufweisen

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Abbreviations

VA:

Vertebral artery

PCA:

Posterior cerebral artery

BA:

Basilar artery

TIMI:

Thrombolysis in myocardial infarction

OTR:

Time interval from onset to recanalization

SICH:

Symptomatic intracranial hemorrhage

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Acknowledgments

AM and MB contributed equally to the manuscript. No other persons apart from the authors have made substantial contributions to this manuscript.

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Authors and Affiliations

  1. Klinik für Radiologie, Neuroradiologie und interventionelle Therapie, Klinikum Vest, Knappschaftskrankenhaus, Dorstener Str. 151, 45657, Recklinghausen, Germany

    A. Mpotsaris & W. Weber

  2. Klinik für Neurologie und Klinische Neurophysiologie, Klinikum Vest, Knappschaftskrankenhaus, Recklinghausen, Germany

    M. Bussmeyer & H. Buchner

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  1. A. Mpotsaris
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Correspondence to A. Mpotsaris.

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Mpotsaris, A., Bussmeyer, M., Buchner, H. et al. 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 23, 207–215 (2013). https://doi.org/10.1007/s00062-013-0197-y

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