Abstract
Extracranial carotid artery occlusion or high-grade stenosis with concomitant intracranial embolism causes severe ischemic stroke and shows poor response rates to intravenous thrombolysis (IVT). Endovascular therapy (EVT) utilizing thrombectomy assisted by carotid stenting was long considered risky because of procedural complexities and necessity of potent platelet inhibition—in particular following IVT. This study assesses the benefits and harms of thrombectomy assisted by carotid stenting and identifies factors associated with clinical outcome and procedural complications. Retrospective single-center analysis of 47 consecutive stroke patients with carotid occlusion or high-grade stenosis and concomitant intracranial embolus treated between September 2011 and December 2014. Benefits included early improvement of stroke severity (NIHSS ≥ 10) or complete remission within 72 h and favorable long-term outcome (mRS ≤ 2). Harms included complications during and following EVT. Mean age was 64.3 years (standard deviation ±12.5), 40 (85 %) patients received IVT initially. Median NIHSS was 16 (inter-quartile range 14–19). Mean time from stroke onset to recanalization was 311 min (standard deviation ±78.0). Early clinical improvement was detected in 22 (46 %) patients. Favorable outcome at 3 months occurred in 32 (68 %) patients. Expedited patient management was associated with favorable clinical outcome. Two (4 %) patients experienced symptomatic hemorrhage. Eight (17 %) patients experienced stent thrombosis. Four (9 %) patients died. Thrombectomy assisted by carotid stenting seems beneficial and reasonably safe with a promising rate of favorable outcome. Nevertheless, adverse events and complications call for additional clinical investigations prior to recommendation as clinical standard. Expeditious patient management is central to achieve good clinical outcome.
Similar content being viewed by others
References
Berkhemer OA, Fransen PSS, Beumer D et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11–20. doi:10.1056/NEJMoa1411587
Jovin TG, Chamorro A, Cobo E et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:2296–2306. doi:10.1056/NEJMoa1503780
Goyal M, Demchuk AM, Menon BK et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372:1019–1030. doi:10.1056/NEJMoa1414905
Rubiera M, Ribo M, Delgado-Mederos R et al (2006) Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke 37:2301–2305. doi:10.1161/01.STR.0000237070.80133.1d
Kim YS, Garami Z, Mikulik R et al (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 36:869–871. doi:10.1161/01.STR.0000160007.57787.4c
Labeyrie M-A, Turc G, Hess A et al (2012) Diffusion lesion reversal after thrombolysis: a MR correlate of early neurological improvement. Stroke 43:2986–2991. doi:10.1161/STROKEAHA.112.661009
Kharitonova T, Mikulik R, Roine RO et al (2011) Association of early National Institutes of Health Stroke Scale improvement with vessel recanalization and functional outcome after intravenous thrombolysis in ischemic stroke. Stroke 42:1638–1643. doi:10.1161/STROKEAHA.110.606194
Hemmen TM, Ernstrom K, Raman R (2011) Two-hour improvement of patients in the National Institute of Neurological Disorders and Stroke trials and prediction of final outcome. Stroke 42:3163–3167. doi:10.1161/STROKEAHA.110.608919
Saver JL, Goyal M, Bonafe A et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372:2285–2295. doi:10.1056/NEJMoa1415061
Campbell BCV, Mitchell PJ, Kleinig TJ et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:1009–1018. doi:10.1056/NEJMoa1414792
Ozdemir O, Bussière M, Leung A et al (2008) Intra-arterial thrombolysis of occluded middle cerebral artery by use of collateral pathways in patients with tandem cervical carotid artery/middle cerebral artery occlusion. AJNR Am J Neuroradiol 29:1596–1600. doi:10.3174/ajnr.A1163
Stampfl S, Ringleb PA, Mohlenbruch M et al (2014) Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 35:741–746. doi:10.3174/ajnr.A3763
Lockau H, Liebig T, Henning T et al (2015) Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 57:589–598. doi:10.1007/s00234-014-1465-5
Heck DV, Brown MD (2014) Carotid stenting and intracranial thrombectomy for treatment of acute stroke due to tandem occlusions with aggressive antiplatelet therapy may be associated with a high incidence of intracranial hemorrhage. J Neurointerv Surg. doi:10.1136/neurintsurg-2014-011224
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 23:207–215. doi:10.1007/s00062-013-0197-y
Kwak HS, Hwang SB, Jin GY et al (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 34:841–846. doi:10.3174/ajnr.A3304
Fischer U, Mono M-L, Schroth G et al (2013) Endovascular therapy in 201 patients with acute symptomatic occlusion of the internal carotid artery. Eur J Neurol 20(1017–24):e87. doi:10.1111/ene.12094
Maurer CJ, Joachimski F, Berlis A (2014) Two in one: endovascular treatment of acute tandem occlusions in the anterior circulation. Clin Neuroradiol. doi:10.1007/s00062-014-0318-2
Higashida RT, Furlan AJ, Roberts H et al (2003) Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 34:109–137. doi:10.1161/01.STR.0000082721.62796.09
Labiche LA, Al-Senani F, Wojner AW et al (2003) Is the benefit of early recanalization sustained at 3 months? A prospective cohort study. Stroke 34:695–698. doi:10.1161/01.STR.0000055940.00316.6B
Wilson JTL, Hareendran A, Grant M et al (2002) Improving the assessment of outcomes in stroke: use of a structured interview to assign grades on the Modified Rankin Scale. Stroke 33:2243–2246. doi:10.1161/01.STR.0000027437.22450.BD
Trouillas P, von Kummer R (2006) Classification and pathogenesis of cerebral hemorrhages after thrombolysis in ischemic stroke. Stroke 37:556–561. doi:10.1161/01.STR.0000196942.84707.71
Cutlip DE, Baim DS, Ho KKL et al (2001) Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. Circulation 103:1967–1971. doi:10.1161/01.CIR.103.15.1967
Kohn MA, Jarrett MS, Senyak J (2015) Sample size calculators. http://www.sample-size.net/sample-size-proportions/. Accessed 28 Aug 2015
Flaherty ML, Kissela B, Khoury JC et al (2013) Carotid artery stenosis as a cause of stroke. Neuroepidemiology 40:36–41. doi:10.1159/000341410
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
None.
Ethical standards
The conduct of this study was approved by the Danish Data Protection Agency (j.nr. 30-1148) and the Danish Health and Medicines Authority (j.nr 3-3013-1017/1/).
Rights and permissions
About this article
Cite this article
Steglich-Arnholm, H., Holtmannspötter, M., Kondziella, D. et al. Thrombectomy assisted by carotid stenting in acute ischemic stroke management: benefits and harms. J Neurol 262, 2668–2675 (2015). https://doi.org/10.1007/s00415-015-7895-0
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00415-015-7895-0