Tandem occlusions treated by endovascular thrombectomy: no difference in outcome between dissection and atherosclerotic cause?
Author: Peter Vanacker, MD PhD, Antwerp University Hospital, Belgium
Endovascular thrombectomy (EVT) of acute stroke related to tandem steno-occlusive lesions in the anterior circulation is technically challenging but may lead to similar outcomes as compared with patients with isolated intracranial occlusions. The potential impact of the two most common carotid steno-occlusive causes (atherosclerotic and dissection) on reperfusion and clinical outcomes after EVT is not clear. These patients were underrepresented in the major RCT’s. The outcomes of patients with tandem lesions from atherosclerotic and dissection treated with ET in a large individual patient data pooled analysis were compared by the TITAN investigators. They combined patients of 18 comprehensive stroke centers. Tandem occlusions were defined by the combination of a proximal intracranial occlusion and cervical carotid artery high-grade stenosis (NASCET ≥ 90%) or occlusion.
Data of prospectively collected consecutive tandem patients (n=295) treated with endovascular trombectomy were analyzed. A total of 65 patients (22%) were linked to an underlying cervical carotid dissection.
The primary and secondary outcomes, adjusted for the age and NIHSS, were:
- rate of favorable outcome (mRS 0-2) was 56.3% vs. 47.6% (p=0.85)
- rate of successful reperfusion (mTICI 2b-3) was 78.5% vs. 74.5% (p=0.13)
- symptomatic intracerebral hemorrhage was 4.5% vs. 5.2% (p=1.0)
- 90-day mortality were 7.8% vs. 15.3% (p=0.94)
- median procedural time was 76 vs. 67 min
To conclude, acute ischemic stroke patients with tandem steno-occlusive disease, irrespective of the underlying pathophysiological mechanism (arteriosclerotic vs. dissection), treated with endovascular thrombectomy have similar 90-day clinical outcomes and safety outcomes. Carotid stenting (alone or combined with angioplasty) was performed in more than 60% of atherosclerotic tandem-occlusions and more than 50% in dissections, with similar clinical outcomes. The latter indication is questionable in case of good developed collaterals, as stent-trombosis and reperfusion injury need to be feared.
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