Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke

Abstract

There is no consensus for the treatment of a tandem occlusion (TO) in a patient presenting with an acute ischemic stroke. In this review article, we will focus on the controversial treatment strategies for TOs. First, we will discuss treatment options including retrograde, antegrade, and delayed approaches. Second, the role of carotid stent placement versus balloon angioplasty for the extracranial occlusion will be presented. Third, anticoagulation and antiplatelet regimens for the treatment TOs published in the literature will be reviewed. Finally, we will discuss whether there is a role for coil occlusion of the cervical carotid artery or whether staged carotid revascularization days after mechanical thrombectomy of the intracranial occlusion maybe appropriate. The optimal treatment strategy of TO has not been established and further larger trials need to be performed to answer the question.

Keywords: angioplasty; embolization; interventional radiology; occlusion; stenosis; stent; stroke.

Fig. 1

A 56-year-old woman with a history of a recent right carotid endarterectomy presents to the hospital 22 hours from last seen normal with stroke-like symptoms and National Institute of Health Stroke Score (NIHSS) of 11. Computed tomographic angiography (CTA) shows occlusion of the right internal carotid artery and an embolus at the right middle cerebral artery (RMCA) bifurcation ( a and b ; black arrows). CT perfusion with the RAPID software shows a 29-mL volume penumbra with no evidence of infarcted tissue ( c ). Initial right anterior oblique (RAO) right common carotid artery (RCCA) angiography shows an occlusion of the right internal carotid artery (RICA) at its origin ( d ; black arrow). The patient subsequently underwent antegrade revascularization with placement of a carotid stent and mechanical thrombectomy of the RMCA embolus. Final lateral RCCA angiography over the neck shows a widely patent RICA ( e ). Final RCCA angiography in the anteroposterior (AP) projection centered over the head shows a widely patent RMCA and right anterior cerebral artery consistent with a thrombolysis in cerebral infarction scale (TICI) score of III ( f ). The patient was discharged 7 days after the stroke with NIHSS of 4.

Fig. 2

A 65-year-old woman who was last seen normal at 10 p.m. on August 20, 2018. She went to an outside hospital, where she initially presented with NIH stroke scale of 10 and was administered intravenous (IV) tPA. She was subsequently transferred to our hospital. Upon presentation to the emergency room, her NIH stroke scale was 15. CT shows a hyperdense RMCA ( a , black arrow). CTA ( b ) shows occlusion of the RICA at its origin black arrow. Initial RCCA angiography ( c ) shows very poor antegrade flow within the cervical segment of the RICA (black arrow). Initial RICA angiography ( d ) shows an embolus within the mid M1 segment thrombolysis in cerebral infarction (TICI) 0 flow (black arrow). The patient was loaded with dual-antiplatelet agents and treated using the retrograde approach. Final RCCA angiography shows a widely patent RMCA with TICI III flow ( e ). The RICA is also widely patent after balloon angioplasty/stent placement ( f ). Approximately 3 hours later, patient had acute deterioration of her neurological exam. CT showed acute intracerebral hemorrhage with midline shift ( g ). The patient was declared brain dead and died.