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. 2014 Nov;7(4):26-31.

Endovascular treatment of tandem internal carotid and middle cerebral artery occlusions

Haitham Dababneh  1 , Asif Bashir  1 , Mohammed Hussain  1 , Waldo R Guerrero  2 , Walter Morgan  3 , Anna Yuzefovich Khanna  3 , J Duffy Mocco  4
Affiliations

Endovascular treatment of tandem internal carotid and middle cerebral artery occlusions

Haitham Dababneh et al. J Vasc Interv Neurol. 2014 Nov.

Abstract

Objective: Extracranial internal carotid artery (ICA) angioplasty and intracranial thrombectomy may be a safe and efficacious therapeutic option for recanalization of a subset of arterial occlusions termed tandem occlusions of Internal carotid artery and Middle cerebral artery (TIM).

Background: Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant ICA occlusion and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. We report our experience on acute ischemic stroke patients with TIM occlusion treated with extracranial ICA angioplasty/stenting and intracranial thrombectomy and/or standard intravenous thrombolysis.

Design/methods: A retrospective analysis of 7 patients from our stroke database was done. 6 patients of the 7 patients were treated with extracranial ICA angioplasty and intracranial thrombectomy and/or intravenous thrombolysis. We examined early neurological improvement (defined by a reduction of National Institutes of Health Stroke Scale (NIHSS) > 8 points). We also evaluated the rate of successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2b or 3.

Results: All but one of the 6 treated patients achieved a TICI score of 2b or 3 signifying successful recanalization. In addition, treated patients had an early reduction of their NIHSS by greater than 8 points. The 1 patient who did not to achieve TICI 2b or 3 also failed to show early neurological improvement. Four of the treated patients had a follow up NIHSS at 90 days of 1 or less and mRS at 90 days of 0.

Conclusions: In cases of tandem occlusions of ICA and MCA, multimodal therapy consistent of intravenous thrombolysis and/or extracranial ICA stenting and intracranial thrombectomy to achieve recanalization may be a safe and efficacious therapeutic option for recanalization. Further prospective studies are warranted.

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Figures

Figure (1):
Figure (1):. CT angiography of the head and neck showing (A) left MCA occlusion (arrowhead) and (B) ICA string sign (arrow)
Figure (2):
Figure (2):. Patient with example of tandem occlusion, (A) proximal ICA occlusion (arrow) and (B) MCA occlusion (arrowhead)
Figure (3):
Figure (3):. CT perfusion maps showing evidence of (A) preserved cerebral blood volume and (B) increased time to peak indicating big tissue at risk with small infarct territory
Figure (4):
Figure (4):. Patient post treatment with (A) ICA stenting (arrow) and (B) thrombectomy of the MCA (arrowhead), showing an evidence of recanalization of both arteries
See this image and copyright information in PMC

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