Setareh Salehi Omran, MD
Intracranial occlusions with an ipsilateral cervical internal carotid artery (ICA) stenosis/occlusion, so-called tandem occlusions, are a frequent cause of anterior circulation strokes. Tandem occlusions can be treated with endovascular therapy, although the best technical strategy for treating the ICA stenosis/occlusion component is unclear.1 In particular, there is great variability in practice with performing carotid artery stenting (CAS) in addition to intracranial thrombectomy.2 It is also unknown whether the etiology of the ICA stenosis/occlusion, either from dissection or atherosclerosis, should impact the decision to perform CAS. While data supports thrombectomy with CAS in tandem occlusions due to atherosclerosis, there is limited data on its safety and efficacy in tandem occlusions from carotid dissection.3
Marnat et al4 examined the safety and outcome of CAS during the treatment of tandem occlusions from carotid dissections using pooled data from two prospectively maintained, multicenter databases (Endovascular Treatment in Ischemic Stroke and Thrombectomy in Tandem Lesion). The analysis included patients who received endovascular therapy for tandem occlusions related to acute cervical carotid dissection between January 2012 and January 2019. The endovascular strategy, stenting protocol, and antithrombotic regimens were chosen by the interventionalist and treating team. Patients were divided in two groups depending on whether they did or did not undergo CAS. The main outcomes of favorable neurological outcome (defined as 90-day mRS 0-2) and successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3) were assessed in both groups. The rates of procedural complications, 90-day mortality, and symptomatic intracerebral hemorrhage were also compared between patients who did and did not undergo CAS. In order to minimize potential bias due to endovascular strategy, the authors performed a sensitivity analysis comparing main clinical outcomes (favorable outcome and overall degree of disability) in the subgroup of patients with successful reperfusion.
A total of 136 patients with tandem occlusion stroke with carotid artery dissection were included in the analysis (mean age 51.9 years, 67.6% men). Intravenous thrombolysis was given in 66.2% of patients, and median onset to puncture time was 218 minutes (interquartile range, 170-290). Nearly half of the included patients were treated with CAS (47.8% with versus 52.2% without CAS). There were no significant differences in baseline characteristics among patients who did and did not receive CAS for their tandem occlusion. CAS appeared safe and was associated with greater rates of successful reperfusion. However, there was no association between CAS and favorable outcome at 90 days. Sensitivity analysis of patients with successful reperfusion continued to show a lack of improved clinical outcome in patients undergoing CAS.
The main strengths of this study lie in its use of a large multicenter patient population. Additionally, this study was limited to tandem occlusions from carotid artery dissection and did not include cases of atherosclerosis, which has a different pathology and risk of future recurrence. The main limitations include the retrospective nature of the study, which may have led to selection bias. Overall, the findings increase our understanding of this not-uncommon clinical scenario and pave the way for future randomized trials evaluating the use of CAS in tandem occlusion strokes.5
References:
1. Assis Z, Menon BK, Goyal M, Demchuk AM, Shankar J, Rempel JL, et al. Acute ischemic stroke with tandem lesions: Technical endovascular management and clinical outcomes from the escape trial. J Neurointerv Surg. 2018;10:429-433.
2. Jacquin G, Poppe AY, Labrie M, Daneault N, Deschaintre Y, Gioia LC, et al. Lack of consensus among stroke experts on the optimal management of patients with acute tandem occlusion. Stroke. 2019;50:1254-1256.
3. Papanagiotou P, Haussen DC, Turjman F, Labreuche J, Piotin M, Kastrup A, et al. Carotid stenting with antithrombotic agents and intracranial thrombectomy leads to the highest recanalization rate in patients with acute stroke with tandem lesions. JACC Cardiovasc Interv. 2018;11:1290-1299.
4. Marnat G, Lapergue B, Sibon I, Gariel F, Bourcier R, Kyheng M, et al. Safety and outcome of carotid dissection stenting during the treatment of tandem occlusions. Stroke. 2020;51:3713-3718.
5. Zhu F, Hossu G, Soudant M, Richard S, Achit H, Beguinet M, et al. Effect of emergent carotid stenting during endovascular therapy for acute anterior circulation stroke patients with tandem occlusion: A multicenter, randomized, clinical trial (titan) protocol. Int J Stroke. 2020:1747493020929948.
