Endovascular retrograde approach may be a better option for acute tandem occlusions stroke

Abstract

Objective: The endovascular treatment strategy for acute tandem occlusion stroke is challenging, and controversy exists regarding which lesion should be treated first. This study addresses the uncertainty regarding the priority choice for thrombectomy in acute anterior circulation tandem occlusion stroke.

Methods: We analysed the clinical and angiographic data of tandem stroke patients who underwent interventional therapy from the endovAsCular Treatment of acUte Anterior circuLation ischaemic stroke (ACTUAL) registry. Recanalisation was assessed according to the modified thrombolysis in cerebral infarction score. Clinical outcome was evaluated at 90 days using the modified Rankin scale score.

Results: Sixty tandem occlusion stroke patients were enrolled. Thirty-one (51.7%) patients received anterograde therapy, while 29 (48.3%) patients underwent the retrograde approach. Successful recanalisation (modified thrombolysis in cerebral infarction score 2b-3) occurred in 78.3% (47/60) of patients, and 50.0% (30/60) of patients achieved a modified Rankin scale score of 0-2 at 90 days. Patients undergoing the retrograde approach spent less time in distal occlusion recanalisation (125 (86-167) vs. 95 (74-122) minutes; P = 0.04) and achieved better functional outcomes at 90 days (69.0% (20/29) vs. 32.3% (10/31); P = 0.004) than patients who received anterograde therapy. The retrograde approach was associated with favourable clinical outcomes (odds ratio 0.21; 95% confidence interval 0.07-0.64; P = 0.006).

Conclusion: For acute tandem occlusion stroke, favourable outcomes were better in patients undergoing retrograde therapy than in patients who received the anterograde approach. Future randomised trials are warranted to determine the optimal treatment.

Keywords: Tandem occlusion; intervention; stroke.

Figure 1.

The anterograde approach. A 74-year-old man, National Institutes of Health stroke scale onset score 15, distal reperfusion time 172 minutes and modified Rankin scale score at 90 days 6. (a) The angiogram showed complete occlusion of the left internal carotid artery (ICA) (arrow). (b, c) Angioplasty was performed with the ICA occlusion. (d, e) After proximal occlusion recanalisation, a stent retriever was deployed at the left middle cerebral artery (MCA) with revascularisation of the vessel. (f) The angiogram demonstrated complete revascularisation of the left ICA and MCA.

Figure 2.

The retrograde approach. A 60-year-old man, National Institutes of Health stroke scale onset score 14, distal reperfusion time 72 minutes and modified Rankin scale score at 90 days 2. (a) Extracranial angiogram showed complete occlusion of the left internal carotid artery (ICA) (arrow). (b) Intracranial angiogram showed a distal middle cerebral artery (MCA) occlusion (arrow) and good leptomeningeal collateralisation. (c) A stent retriever was deployed at the left distal MCA occlusion. (d) After thrombectomy with the stent retriever, successful recanalisation of the MCA segments was achieved (arrow). (e, f) The angiogram demonstrated successful reconstruction of the left ICA lumen after stent implantation and angioplasty.