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Randomized Controlled Trial
. 2018 May;10(5):429-433.
doi: 10.1136/neurintsurg-2017-013316. Epub 2017 Oct 11.

Acute ischemic stroke with tandem lesions: technical endovascular management and clinical outcomes from the ESCAPE trial

Zarina Assis  1 , Bijoy K Menon  1 , Mayank Goyal  1 , Andrew M Demchuk  1 , Jai Shankar  2 , Jeremy L Rempel  3 , Daniel Roy  4 , Alexander Y Poppe  5 , Victor Yang  6 , Cheemun Lum  7 , Dar Dowlatshahi  8 , John Thornton  9 , Hana Choe  10 , Paul A Burns  11 , Donald F Frei  12 , Blaise W Baxter  13 , Michael D Hill  1   14 ; ESCAPE Trialists
Affiliations
Randomized Controlled Trial

Acute ischemic stroke with tandem lesions: technical endovascular management and clinical outcomes from the ESCAPE trial

Zarina Assis et al. J Neurointerv Surg. 2018 May.

Abstract

Background: Tandem occlusions of the extracranial carotid and intracranial carotid or middle cerebral artery have a particularly poor prognosis without treatment. Several management strategies have been used with no clear consensus recommendations. We examined subjects with tandem occlusions enrolled in the ESCAPE trial and their outcomes.

Methods: Data are from the ESCAPE trial. Additional data were sought on interventions for each subject.

Results: There were 54 (17%) subjects with tandem extracranial and intracranial occlusions. Patients in the endovascular treatment arm (n=30) were more likely to be younger (median age 66 years, p<0.01), male (66.7%, p=0.03), diabetic, and without atrial fibrillation. Subjects with tandem occlusions were more likely to have intracranial internal carotid artery occlusions than M1 occlusions (p<0.01). Of the 30 intervention-arm subjects, 17 (57%) underwent emergency endovascular treatment of the extracranial disease, 10 subjects before and seven subjects after intracranial thrombectomy. Of the remaining 13 subjects, only four required staged carotid revascularization due to persistent severe carotid stenosis; four had cervical pseudo-occlusions with no residual stenosis after large distal carotid thrombus burden aspiration/retrieval. Outcomes were similar between subjects with and without tandem lesions. The use of antithrombotic agents after acute carotid artery stenting was variable but no symptomatic intracerebral hemorrhage was seen in subjects who underwent emergency endovascular treatment of extracranial carotid artery.

Conclusions: Tandem occlusions occurred in one-sixth of patients and were treated highly variably within the ESCAPE trial. While outcomes were similar, the best method to treat the carotid artery in patients with tandem occlusion awaits further randomized data.

Trial registration number: NCT01778335.

Keywords: carotid occlusion; endovascular treatment; randomized controlled trial; stroke.

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Conflict of interest statement

Competing interests: Conflicts of interest: BKM: membership of the Steering and Executive Committee, ESCAPE trial that received support from Covidien; Site Principal Investigator, SOCRATES Trial, sponsored by Astra Zeneca; honoraria from Penumbra; a provisional patent 62/086,077 for triaging systems in ischemic stroke; research funding from Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Canada, Alberta Innovates Health Solutions, Hotchkiss Brain Institute and the Faculty of Medicine, University of Calgary and salary support from CIHR; holds the current Heart and Stroke Foundation/University of Calgary Professorship in Stroke Imaging and receives salary support through the CIHR New Investigator Award. MG: partial support for ESCAPE trial provided to University of Calgary; helped in design and conduct of SWIFT PRIME trial (compensation significant (>$10,000 or 5%)); compensation for speaking engagements from Covidien (significant) and Stryker (modest); patent for Systems of stroke diagnosis licensed to GE Healthcare (compensation significant). AMD: research support from Covidien/Medtronic; unrestricted grant for ESCAPE trial (no compensation); Speaker’s Bureau: Medtronic (significant >$10,000 compensation). DR: grants and personal fees from University of Calgary during the conduct of the study. JT: personal fees from Neuravi, Galway and Ireland outside the submitted work. DFF: personal fees from Covidien, Stryker, Penumbra, Microvention and Siemens during the conduct of the study. BWB: personal fees from Penumbra, Stryker Neurovascular, Covidien (Medtronic), Rapid Medical and Silk Road Medical outside the submitted work. MDH: grants from Covidien (Medtronic), Alberta Innovates Health Solutions, Heart & Stroke Foundation, Hotchkiss Brain Institute, Canadian Stroke Prevention Intervention Networks (CSPIN) (Institute of Circulatory and Respiratory Health, CIHR), Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, non-financial support from Alberta Health Services during the conduct of the study; personal fees from Merck; non-financial support from Hoffmann-La Roche Canada outside the submitted work; patent Systems and Methods for Assisting in Decision-Making and Triaging for Acute Stroke Patients pending to US Patent Office Number: 62/086,077 and owns stock in Calgary Scientific, a company that focuses on medical imaging software. The other authors report no conflicts of interest.

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