Endovascular treatment of tandem occlusions of the anterior cerebral circulation with solitaire FR thrombectomy system. Initial experience

doi:10.1016/j.ejrad.2011.12.032

European Journal of Radiology

Volume 81, Issue 11, November 2012, Pages 3479-3484

https://doi.org/10.1016/j.ejrad.2011.12.032 Get rights and content

Abstract

Purpose

The optimal treatment in the acute phase of cervical internal carotid occlusion associated with intracranial obstruction is a matter of debate. In this study, we report our experience using the Solitaire FR revascularization device and synchronous intravenous fibrinolysis. The distal occlusion was treated with Solitaire FR before the proximal one in all cases, a technique not reported so far in the literature.

Methods

We examined all cases of tandem occlusion treated in our institution between November 2009 and November 2010. The proximal occlusion was treated using manual thromboaspiration in order to achieve intracranial recanalization as rapid as possible. When necessary, stenting was performed after the reconstitution of the intracranial vessel. Morphological and clinical results were recorded in the immediate post-operative phase and at the three-month follow-up. Clinical success was defined as a mRS at 3 months ≤2.

Results

Four male and six female patients were treated (mean age 66 years). The cervical carotid was recanalized in all cases and the intracranial vessel (TICI ≥ 2b) in eight. Adverse events were recorded in four patients of which three were asymptomatic. These included two cases of subarachnoid hemorrhage, one case of traumatic dissection, and one case of fatal intra-cerebral hemorrhage seven days following the procedure. At the three-month follow-up a mRS ≤ 2 was observed in four patients.

Conclusions

The described approach for the treatment of tandem occlusions is promising with regard to both morphological and clinical assessments and thus may be considered a valid tool in acute stroke.

Introduction

The optimal treatment in the acute phase of the cervical internal carotid artery (CICA) occlusion associated with carotid bifurcation (carotid “T”) or middle cerebral artery (MCA) occlusion is a matter of debate. In cases of “tandem obstruction”, it has been reported that a relatively small number of patients fully recanalize and improve their neurological deficits following intra-venous fibrinolysis (IVF) with rtPA [1]. This has encouraged the development of alternative approaches such as the combination of IV with intra-arterial (IA) administration of thrombolytics or the association of IVF with percutaneous transluminal mechanical thrombectomy (MTB).

The aim of the present study is to analyze the efficacy and safety of the endovascular approach currently used in our institution in which the proximal occlusion is managed using manual thrombaspiration or angioplasty without stenting in order to allow treatment of the distal occlusion first. The rational for this approach is to ensure prompt positioning of the guiding catheter downstream the proximal occlusion and to attempt recanalization of the intracranial vessel as fast as possible with the Solitaire FR revascularization device. The definitive treatment of the proximal occlusion is performed secondarily, only after the distal vessel has been recanalized, and is adapted according to the degree of stenosis. This approach potentially eliminates the need of antithrombotic drugs, mandatory in cases of stenting of the proximal cervical carotid artery, and which are related to high risk of hemorrhagic complications. To our knowledge, this technique has not been reported in the literature to date.

Section snippets

Sample

All cases of acute ischemic stroke secondary to a tandem occlusion treated in our institution between November 2009 and November 2010 were retrieved from a prospectively maintained stroke patients database. According to our institutional stroke protocol [1], patients presenting within the first 6 h from symptoms onset with a tandem occlusion are eligible for MTB (in association with IV administration of rt-PA [0.9 mg/kg] if within 4:30 h from stroke onset)

Patient assessment

A baseline NIHSS was obtained by a

Sample

Between November 2009 and November 2010 four male and six female patients presented at our institution in the acute phase of an ischemic stroke secondary to tandem occlusions and were eligible for endovascular treatment (Table 1).

The mean age at treatment was 66 years (range 30–84) and the mean baseline NIHSS was 17 (range 7–21). The average time from the onset of symptoms to hospital admission was 123 min [2:03 h] (range 59–240). Seven patients underwent combined therapy. Three patients

Discussion

Patients treated in the acute phase of ischemic stroke secondary to tandem occlusion present with relatively low rates of recanalization after intravenous fibrinolysis when compared to those with isolated MCA occlusion [4], [5], [6]. As a consequence, there has been a significant disparity in the neurological outcome reported, so that such tandem occlusions are now recognized as an independent risk factor of poor outcome in patients treated with systemic thrombolysis [7], [8], [9]. Occlusions

Conclusion

The number of patients in our case series is small and heterogeneous (NIHSS: 7–21, age 30–84). In addition our study is retrospective and non-randomized. Nevertheless to our knowledge, no prospective, randomized trial, assessing the most effective treatment for tandem occlusions has been reported so far. In addition, although a number of case series have assessed different therapeutic approaches to this challenging pathology, no study utilizes the Solitaire FR consistently for revascularization

Disclosure

A. Bonafé is consultant for Cordis Corporation, EV3, Microvention. P. Machi is consultant for Stryker Neurovascular.

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Cited by (32)

Endovascular Therapy Strategy for Acute Embolic Tandem Occlusion: The Pass-Thrombectomy-Protective Thrombectomy (Double PT) Technique
2018, World Neurosurgery
Citation Excerpt :
Endovascular therapy can rapidly open the occluded large artery and save the ischemic penumbra tissue, leading to improvement of prognosis in these patients.2 The endovascular strategy of stenotic ICA tandem occlusion has been reported by many studies.2-11 However, strategies for acute embolic tandem occlusion involving the common carotid artery (CCA) or ICA embolism concomitant with an intracranial artery embolism are rare.
Embolic occlusions of the common carotid artery (CCA)/internal carotid artery (ICA) and intracranial artery occlusions in acute ischemic stroke are associated with high morbidity and can benefit from endovascular therapy. However, the optimal endovascular strategy for these conditions is unclear. This study aimed to evaluate the feasibility of the pass-thrombectomy-protective thrombectomy (double PT) technique and the clinical outcome of treated patients.
We collected data on embolic occlusion of the CCA/ICA and intracranial artery occlusion in our prospective stroke registry database between January 2015 and February 2017. Clinical and angiographic data were retrospectively analyzed. Clinical outcome was evaluated at 3 months (modified Rankin scale [mRS] score), and an mRS score of 2 or lower was defined as a good clinical outcome.
A total of 7 patients with tandem occlusion were included, with a mean age of 66 years. The median admission National Institutes of Health Stroke Scale score was 20, and 6 of 7 patients (85.7%) underwent successful recanalization. The median reperfusion time of the affected intracranial artery was 61 minutes. The rate of good clinical outcome was 42.9% (3/7), the mortality rate was 14.3% (1/7), and the embolic event rate was 14.3% (1/7) when the proximal clot was retrieved.
The double PT technique is feasible and safe in treating initial embolic tandem occlusion of the CCA/ICA.
Another Endovascular Therapy Strategy for Acute Tandem Occlusion: Protect-Expand-Aspiration-Revascularization-Stent (PEARS) Technique
2018, World Neurosurgery
Citation Excerpt :
The main aim of our study was to present the technique of the half anterograde approach for TO. Previously reported common techniques are the anterograde approach12-18 and retrograde approach.9,19 Our technique of the half anterograde approach involved clot retrieval after balloon dilatation of the ICA initial segment.
Initial stenotic occlusion of the internal carotid artery with intracranial artery occlusion in acute ischemic stroke is associated with high morbidity and can benefit from endovascular therapy. However, the optimal endovascular strategy is unclear. This study aimed to evaluate the feasibility of the “half” anterograde approach and clinical outcome of treated patients. Revascularization validity of the 2 “half” anterograde approach with (Protect-Expand-Aspiration-Revascularization-Stent [PEARS] technique) or without (plain technique) using an embolic prevention device and aspiration was also compared.
Data on initial stenotic occlusion of the internal carotid artery with intracranial artery occlusion in our prospective stroke registry database between January 2015 and February 2017 were collected. Clinical and angiographic data were retrospectively analyzed. Clinical outcome was evaluated at 3 months, defined as a modified Rankin scale ≤2 as a good clinical outcome.
Overall, 26 patients with tandem occlusion were included; 96.3% of patients had successful recanalization. The rate of a good clinical outcome was 61.8%, symptomatic parenchymal hemorrhage was 7.7%, and mortality was 15.4%. The PEARS technique took less time (56 ± 14 vs. 97 ± 31 minutes; P = 0.002) and had less embolic events (0 vs. 30.8%; P = 0.012) compared with the plain technique. Use of the PEARS technique was an independent predictor for shortening revascularization time (β = −0.651, P = 0.001).
The half anterograde approach technique is feasible and safe for treating tandem occlusion. Furthermore, the PEARS technique is associated with a shorter reperfusion time and less embolic events than the plain technique, and should be recommended in tandem occlusion.
Re: Endovascular Stroke Treatment of Acute Tandem Occlusion: A Single-Center Experience
2017, Journal of Vascular and Interventional Radiology
Recanalization therapy for internal carotid artery occlusion presenting as acute ischemic stroke
2014, Journal of Stroke and Cerebrovascular Diseases
We aimed to describe the current status and clinical outcomes of recanalization therapy for internal carotid artery occlusion (ICAO) presenting as acute ischemic stroke.
Using a nationwide stroke registry database in Korea, we identified consecutive ischemic stroke patients with ICAO hospitalized within 12 hours of onset between March 2010 and November 2011.
ICAO accounted for 10.6% (322 of 3028) of acute ischemic strokes within 12 hours of onset. Among the 322 ICAO patients, 53% underwent recanalization therapy, 41% intravenous thrombolysis (IVT) alone, and 59% endovascular treatment (EVT). Twenty-two percent of those with mild deficits (National Institutes of Health Stroke Scale <4) and 50% of those 80 years of age or more received recanalization therapy. Compared with no treatment, recanalization therapy was not significantly associated with a favorable outcome (3-month modified Rankin scale, 0-2) (adjusted odds ratio [OR], 1.77; 95% confidence interval [CI], .80-3.91; P = .16). However, compared with IVT, EVT significantly improved the odds of favorable outcome (OR, 2.86; 95% CI, 1.19-6.88; P = .02) without significant increase of symptomatic intracranial hemorrhage (OR, 2.18; 95% CI, .42-11.43; P = .36) and 3-month mortality (OR, .53; 95% CI, .23-1.18; P = .12). Successful recanalization rate (Thrombolysis in Cerebral Infarction ≥2a) by EVT was 76%.
In Korea, one tenth of acute ischemic stroke was caused by ICAO, and about 50% were treated by recanalization therapy. EVT was widely used as a recanalization modality (about 60% of cases) despite lack of evidence. However, its effectiveness and safety were acceptable.
Endovascular procedures versus intravenous thrombolysis in stroke with tandem occlusion of the anterior circulation
2014, Journal of Vascular and Interventional Radiology
Stroke with tandem occlusion within the anterior circulation presents a lower probability of recanalization and good clinical outcome after intravenous (IV) thrombolysis than stroke with single occlusion. The present study describes the impact of endovascular procedures (EPs) compared with IV thrombolysis alone on recanalization and clinical outcome.
Thirty patients with symptom onset less than 4.5 hours and tandem occlusion within the anterior circulation were analyzed retrospectively. Recanalization was assessed per Thrombolysis In Cerebral Infarction (TICI) classification on computed tomography, magnetic resonance imaging, or digital subtraction angiography within 24 hours. Infarct size was detected on follow-up imaging as a dichotomized variable, ie, more than one third of the territory of the middle cerebral artery. Clinical outcomes were major neurologic improvement, independent outcome (90-d modified Rankin Scale [mRS] score), symptomatic intracerebral hemorrhage (sICH; per European Cooperative Acute Stroke Study criteria), and death within 7 days.
Patients treated with EPs (n = 14) were significantly younger and had a history of arterial hypertension more frequently than patients treated with IV thrombolysis alone (n = 16). Recanalization (ie, TICI score 2b/3; EP, 64%; IV, 19%; P = .01), major neurologic improvement (EP, 64%; IV, 19%; P = .01), and independent outcome (mRS score ≤ 2; EP, 54% IV, 13%; P = .02) occurred more often in the EP group, whereas infarct sizes greater than one third of the MCA territory (EP, 43%; IV, 81%; P = .03) were observed less often. Rates of sICH (P = .12) and death within 7 days (P = .74) did not differ significantly.
Higher recanalization rate, smaller infarct volume, and better clinical outcome in the EP group should encourage researchers to include this subgroup of patients in prospective randomized trials comparing IV thrombolysis versus EP in stroke.
Outcome after mechanical thrombectomy using a stent retriever under conscious sedation: Comparison between tandem and single occlusion of the anterior circulation
2014, Journal of Neuroradiology
Citation Excerpt :
Recently, however, the use of stent retrievers to treat this specific type of occlusion has led to improved recanalization rates and outcomes. Indeed, several mechanical thrombectomy techniques have been proposed and shown to have promising results, with equivalent rates of recanalization and good functional outcomes compared with single occlusions [9–12,15–18]. These findings are in accord with previous risk-factor analyses of thrombectomy that did not observe any link between tandem occlusions and poorer outcomes [19,20].
In acute ischemic stroke patients, internal carotid artery/middle cerebral artery (ICA/MCA) occlusion in tandem predicts a poor outcome after systemic thrombolysis. This study aimed to compare outcomes after mechanical thrombectomy for tandem and single occlusions of the anterior circulation.
This prospective study included consecutive patients with acute ischemic stroke of the anterior circulation who had undergone mechanical thrombectomy performed with a stent retriever under conscious sedation within 6 h of symptom onset. Data on clinical, imaging and endovascular findings were collected. In cases of tandem occlusion, distal thrombectomy (retrograde approach) was performed first whenever possible. Tandem and single occlusions were compared in terms of functional outcome and mortality at 3 months.
From May 2010 to April 2012, 42 patients with acute ischemic stroke attributable to MCA and/or ICA occlusion were treated. Eleven patients (26.2%) presented with tandem occlusions and 31 patients (73.8%) had a single anterior circulation occlusion. Baseline characteristics were similar between the two groups. Recanalization status also did not differ significantly (P = 0.76), but patients with tandem occlusions had poorer functional outcomes (18.2% vs. 67.7% for single occlusions; P = 0.01), a higher mortality rate at 3 months (45.5% vs. 12.9%, respectively; P = 0.03) and more symptomatic intracranial hemorrhages at 24 h (9.7% vs. 0%, respectively; P = 0.01). A high rate of early proximal re-occlusion or severe residual stenosis (66%) was also observed in the tandem group.
Tandem occlusions had poor clinical outcomes after mechanical thrombectomy compared with single occlusions. The retrograde approach (treatment of distal occlusion first) used in patients under conscious sedation may have contributed to these poor outcomes.

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¹: Present address: CHRU Montpellier. Service de Neuroradiologie, Hopital Gui de Chauliac, 80, Avenue Augustin Fliche. 34295 Montpellier Cedex 5, France. Tel.: +33 4 6733 0286; fax: +33 4 6733 7884.

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Endovascular treatment of tandem occlusions of the anterior cerebral circulation with solitaire FR thrombectomy system. Initial experience

Abstract

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Sample

Patient assessment

Sample

Discussion

Conclusion

Disclosure

Rescue, combined, and stand-alone throbectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study timing, safety, and efficacy

Stroke

Large ischemic lesions on diffusion-weighted imaging done before intravenous tissue plasminogen activator thrombolysis predicts a poor outcome in patients with acute stroke

Stroke

Solitaire™ FR thrombectomy system. Immediate results in 56 consecutive acute ischemic stroke patients

J Neurointervent Surg

Trial design and reporting standards for intraarterial cerebral thrombolysis for acute ischemic stroke

Stroke

Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion

Stroke

Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator

Stroke

Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis

Stroke

Predictors of early arterial reocclusion after tissue plasminogen activator unduced recanalization in acute ischemic stroke

Stroke

Ultrasound identification and lysis of clots

Stroke

Tissue plasminogen activator for acute ischemic stroke

New Engl J Med