Endovascular treatment of tandem occlusions of the anterior cerebral circulation with solitaire FR thrombectomy system. Initial experience
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 NeurosurgeryCitation 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.
Another Endovascular Therapy Strategy for Acute Tandem Occlusion: Protect-Expand-Aspiration-Revascularization-Stent (PEARS) Technique
2018, World NeurosurgeryCitation 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.
Re: Endovascular Stroke Treatment of Acute Tandem Occlusion: A Single-Center Experience
2017, Journal of Vascular and Interventional RadiologyRecanalization therapy for internal carotid artery occlusion presenting as acute ischemic stroke
2014, Journal of Stroke and Cerebrovascular DiseasesEndovascular procedures versus intravenous thrombolysis in stroke with tandem occlusion of the anterior circulation
2014, Journal of Vascular and Interventional RadiologyOutcome after mechanical thrombectomy using a stent retriever under conscious sedation: Comparison between tandem and single occlusion of the anterior circulation
2014, Journal of NeuroradiologyCitation 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].
- 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.