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Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results

  • Interventional Neuroradiology
  • Published:
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An Editorial to this article was published on 10 April 2015

Abstract

Introduction

Acute tandem occlusions of the cervical and distal internal carotid artery (ICA) or middle cerebral artery (MCA) are associated with major stroke with intravenous (i.v.) thrombolysis alone in approximately 90 % of patients. The data on endovascular management of tandem occlusions is still limited. The purpose of this study was to review technical aspects and the current state of the literature on acute ICA stenting in combination with stent retriever-based intracranial thrombectomy.

Methods

We retrospectively reviewed the data of 37 consecutive patients with tandem occlusions including clinical parameters, angiographic results, procedural aspects, complications, and hemorrhages.

Results

Median National Institutes of Health Stroke Scale (NIHSS) on admission was 17 (3–30). Intracranial thrombectomy was performed prior to ICA stenting in 25/37 (67.6 %) and after stenting in 12/37 (32.4 %) patients. ICA stenting was successful in all cases, and a thrombolysis in cerebral infarction (TICI) scale 2b/3 result was achieved in 27/37 (73 %) cases. The mean angiography time was significantly shorter in the “thrombectomy first” group (43.1 ± 30.8 vs. 110.8 ± 43.0 min, p < 0.001), and more patients had favorable outcomes after 3 months (13/25 = 52.0 vs. 4/12 = 33.3 %, p = 0.319). In this group, intermediate catheters were used and successfully prevented embolism to unaffected territories in all cases.

Conclusion

Acute stenting of the cervical ICA in combination with intracranial thrombectomy was technically feasible and safe in our series. Thrombectomy prior to proximal stenting was associated with shorter reperfusion times and a tendency towards better clinical outcome leading to a good outcome in about 50 % of the patients. Therefore, we recommend this approach in tandem occlusion requiring stent angioplasty.

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References

  1. Adams HP Jr, Bendixen BH, Leira E, Chang KC, Davis PH, Woolson RF, Clarke WR, Hansen MD (1999) Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 53(1):122–125

    Article  CAS  PubMed  Google Scholar 

  2. Linfante I, Llinas RH, Selim M, Chaves C, Kumar S, Parker RA, Caplan LR, Schlaug G (2002) Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator. Stroke 33(8):2066–2071

    Article  PubMed  Google Scholar 

  3. Christou I, Felberg RA, Demchuk AM, Burgin WS, Malkoff M, Grotta JC, Alexandrov AV (2002) Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion. J Neuroimaging 12(2):119–123

    Article  PubMed  Google Scholar 

  4. Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV, CLOTBUST Collaborators (2005) Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke 36(4):869–871

    Article  PubMed  Google Scholar 

  5. Rubiera M, Alvarez-Sabín J, Ribo M, Montaner J, Santamarina E, Arenillas JF, Huertas R, Delgado P, Purroy F, Molina CA (2005) Predictors of early arterial reocclusion after tissue plasminogen activator-induced recanalization in acute ischemic stroke. Stroke 36(7):1452–1456

    Article  PubMed  Google Scholar 

  6. Saqqur M, Uchino K, Demchuk AM, Molina CA, Garami Z, Calleja S, Akhtar N, Orouk FO, Salam A, Shuaib A, Alexandrov AV, CLOTBUST Investigators (2007) Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke 38(3):948–954

    Article  PubMed  Google Scholar 

  7. Pérez MA, Miloslavski E, Fischer S, Bäzner H, Henkes H (2012) Intracranial thrombectomy using the Solitaire stent: a historical vignette. J Neurointerv Surg 4(6):e32

    Article  PubMed Central  PubMed  Google Scholar 

  8. Nesbit GM, Clark WM, O'Neill OR, Barnwell SL (1996) Intracranial intraarterial thrombolysis facilitated by microcatheter navigation through an occluded cervical internal carotid artery. J Neurosurg 84(3):387–392

    Article  CAS  PubMed  Google Scholar 

  9. Jovin TG, Gupta R, Uchino K, Jungreis CA, Wechsler LR, Hammer MD, Tayal A, Horowitz MB (2005) Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke 36(11):2426–2430

    Article  PubMed  Google Scholar 

  10. Hui FK, Hussain MS, Elgabaly MH, Sivapatham T, Katzan IL, Spiotta AM (2011) Embolic protection devices and the Penumbra 054 catheter: utility in tandem occlusions in acute ischemic stroke. J Neurointerv Surg 3(1):50–53

    Article  PubMed  Google Scholar 

  11. Papanagiotou P, Roth C, Walter S, Behnke S, Grunwald IQ, Viera J, Politi M, Körner H, Kostopoulos P, Haass A, Fassbender K, Reith W (2011) Carotid artery stenting in acute stroke. J Am Coll Cardiol 58(23):2363

    Article  PubMed  Google Scholar 

  12. Matsubara N, Miyachi S, Tsukamoto N, Kojima T, Izumi T, Haraguchi K, Asai T, Yamanouchi T, Ota K, Wakabayashi T (2013) Endovascular intervention for acute cervical carotid artery occlusion. Acta Neurochir (Wien) 155(6):1115–1123

    Article  Google Scholar 

  13. Hauck EF, Natarajan SK, Ohta H, Ogilvy CS, Hopkins LN, Siddiqui AH, Levy EI (2011) Emergent endovascular recanalization for cervical internal carotid artery occlusion in patients presenting with acute stroke. Neurosurgery 69(4):899–907

    Article  PubMed  Google Scholar 

  14. Malik AM, Vora NA, Lin R, Zaidi SF, Aleu A, Jankowitz BT, Jumaa MA, Reddy VK, Hammer MD, Wechsler LR, Horowitz MB, Jovin TG (2011) Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience. Stroke 42(6):1653–1657

    Article  PubMed  Google Scholar 

  15. Matsubara N, Miyachi S, Tsukamoto N, Kojima T, Izumi T, Haraguchi K, Asai T, Yamanouchi T, Ota K, Wakabayashi T (2013) Endovascular intervention for acute cervical carotid artery occlusion. Acta Neurochir (Wien) 155(6):1115–1123

    Article  Google Scholar 

  16. Higashida RT, Furlan AJ, Roberts H, Tomsick T, Connors B, Barr J, Dillon W, Warach S, Broderick J, Tilley B, Sacks D (2003) Technology Assessment Committee of the American Society of Interventional and Therapeutic Neuroradiology; Technology Assessment Committee of the Society of Interventional Radiology. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 34(8):e109–137

    Article  PubMed  Google Scholar 

  17. Dorn F, Stehle S, Lockau H, Zimmer C, Liebig T (2012) Endovascular treatment of acute intracerebral artery occlusions with the Solitaire stent: single-centre experience with 108 recanalization procedures. Cerebrovasc Dis 34:70–77

    Article  CAS  PubMed  Google Scholar 

  18. Davalos A, Pereira VM, Chapot R, Bonafe A, Andersson T, Gralla J (2012) Retrospective multicenter study of Solitaire FR for revascularization in the treatment of acute ischemic stroke. Stroke 43:2699–2705

    Article  PubMed  Google Scholar 

  19. Pereira VM, Gralla J, Davalos A, Bonafe A, Castano C, Chapot R et al (2013) Prospective, multicenter, single-arm study of mechanical thrombectomy using solitaire flow restoration in acute ischemic stroke [STAR]. Stroke 44(10):2802–2807

    Article  PubMed Central  PubMed  Google Scholar 

  20. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO, SWIFT Trialists (2012) Solitaire flow restoration device versus the Merci retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 380(9849):1241–1249

    Article  PubMed  Google Scholar 

  21. Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, Liebeskind DS, Smith WS, TREVO 2 Trialists (2012) Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 380(9849):1231–1240

    Article  PubMed Central  PubMed  Google Scholar 

  22. Grau AJ, Weimar C, Buggle F, Heinrich A, Goertler M, Neumaier S, Glahn J, Brandt T, Hacke W, Diener HC (2001) Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke 32(11):2559–2566

    Article  CAS  PubMed  Google Scholar 

  23. Kwak HS, Hwang SB, Jin GY, Hippe DS, Chung GH (2013) Predictors of functional outcome after emergency carotid artery stenting and intra-arterial thrombolysis for treatment of acute stroke associated with obstruction of the proximal internal carotid artery and tandem downstream occlusion. AJNR Am J Neuroradiol 34(4):841–846

    Article  CAS  PubMed  Google Scholar 

  24. Mpotsaris A, Bussmeyer M, Buchner H, Weber W (2013) 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(3):207–215

    Article  CAS  PubMed  Google Scholar 

  25. Son S, Choi DS, Oh MK, Kim SK, Kang H, Park KJ, Choi NC, Kwon OY, Lim BH (2014) Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience. J Neurointerv Surg. 14

  26. Cohen JE, Gomori JM, Rajz G, Itshayek E, Eichel R, Leker RR (2014) Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandem occlusive disease. J Neurointerv Surg 12

  27. Stampfl S, Ringleb PA, Möhlenbruch M, Hametner C, Herweh C, Pham M, Bösel J, Haehnel S, Bendszus M, Rohde S (2014) Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 35(4):741–746

    Article  CAS  PubMed  Google Scholar 

  28. Fischer U, Mono ML, Schroth G, Jung S, Mordasini P, El-Koussy M, Weck A, Brekenfeld C, Findling O, Galimanis A, Heldner MR, Arnold M, Mattle HP, Gralla J (2013) Endovascular therapy in 201 patients with acute symptomatic occlusion of the internal carotid artery. Eur J Neurol 20(7):1017–1024

    Article  CAS  PubMed  Google Scholar 

  29. Rha JH, Saver JL (2007) The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 38(3):967–973

    Article  PubMed  Google Scholar 

  30. Spiotta AM, Lena J, Vargas J, Hawk H, Turner RD, Chaudry MI, Turk AS (2014) Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke. J Neurointerv Surg 21.

  31. Komiyama M, Nishio A, Nishijima Y (1994) Endovascular treatment of acute thrombotic occlusion of the cervical internal carotid artery associated with embolic occlusion of the middle cerebral artery: case report. Neurosurgery 34(2):359–363

    Article  CAS  PubMed  Google Scholar 

  32. Nesbit GM, Clark WM, O’Neill OR, Barnwell SL (1996) Intracranial intraarterial thrombolysis facilitated by microcatheter navigation through an occluded cervical internal carotid artery. J Neurosurg 84(3):387–392

    Article  CAS  PubMed  Google Scholar 

  33. Nedeltchev K, Brekenfeld C, Remonda L, Ozdoba C, Do DD, Arnold M, Mattle HP, Schroth G (2005) Internal carotid artery stent implantation in 25 patients with acute stroke: preliminary results. Radiology 237(3):1029–1037

    Article  PubMed  Google Scholar 

  34. Castano C, Dorado L, Guerrero C, Millan M, Gomis M, La Perez De Ossa N et al (2010) Mechanical thrombectomy with the solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke 41:1836–1840

    Article  PubMed  Google Scholar 

  35. Akins PT, Amar AP, Pakbaz RS, Fields JD (2014) Complications of endovascular treatment for acute stroke in the SWIFT trial with solitaire and Merci devices. AJNR Am J Neuroradiol 35:524–528

    Article  CAS  PubMed  Google Scholar 

  36. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1588

    Article  Google Scholar 

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Ethical standards and patient consent

We declare that all human and animal studies have been approved by the local Ethics Committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. We declare that all patients gave informed consent prior to inclusion in this study.

Conflict of interest

TL consults for Concentric, now part of Stryker.

Author information

Authors and Affiliations

  1. Department of Radiology, University Hospital of Cologne, Kerpenerstr. 62, 50937, Cologne, Germany

    H. Lockau, T. Liebig, T. Henning, C. Kabbasch & F. Dorn

  2. Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany

    V. Neuschmelting

  3. Department of Neurology, University Hospital of Cologne, Cologne, Germany

    H. Stetefeld

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  1. H. Lockau
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  2. T. Liebig
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  3. T. Henning
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  6. C. Kabbasch
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  7. F. Dorn
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Corresponding author

Correspondence to F. Dorn.

Additional information

H Lockau and T Liebig contributed equally to the manuscript and share joint first authorship.

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Lockau, H., Liebig, T., Henning, T. et al. Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 57, 589–598 (2015). https://doi.org/10.1007/s00234-014-1465-5

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  • DOI: https://doi.org/10.1007/s00234-014-1465-5

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