Endovascular treatment of acute ischemic stroke due to tandem lesions of the anterior cerebral circulation: a multicentric Italian observational study

Abstract

Purpose: Acute ischemic stroke (AIS) due to tandem lesions (TLs) of extracranial Internal Carotid Artery and Anterior Cerebral Circulation are challenging for endovascular treatment (EVT). This study aims to evaluate feasibility, safety and efficacy of EVT for TLs' AIS, with or without emergent carotid artery stenting (eCAS), in a real-life scenario.

Methods: Retrospective review of prospectively collected non-randomized thrombectomy databases from five stroke centers between 2015 and 2019. Consecutive patients with TLs' AIS were selected. Clinical, neuroimage and procedure features, as well as antiplatelet therapy regimen, were evaluated. Primary outcome was 90-day mRS ≤ 2. Secondary outcomes included: mTICI score 2b-3, extracranial recanalization, procedural complications, symptomatic intracerebral hemorrhage (SICH) and 90-day mortality.

Results: Two hundred twenty-seven patients were enrolled (67.8% males; mean age 65.9 ± 12.9 years). We obtained mTICI 2b-3 in 77.1%, extracranial recanalization in 86.8%, 90-day mRS (available in 201/227 cases) ≤ 2 in 49.8%. Procedural complications occurred in 16.7%, SICH in 9.7%; 90-day mortality rate (available in 201/227 cases) was 14.4%. The strongest predictors of good clinical outcome were young age (p < 0.0001), low baseline NIHSS (p = 0.008), high baseline ASPECTS (p < 0.0001), good collateral flow (p = 0.013) and extracranial recanalization (p = 0.001). The most significant predictors of SICH were low baseline ASPECTS (p < 0.0001), occurrence of complications (p < 0.0001) and eCAS (p = 0.002).

Conclusion: In our real-life series, the EVT for TLs' AIS was feasible, safe and effective in improving 90-day functional outcome with acceptable morbi-mortality rates. ECAS increased the risk of SICH, independently from the antiplatelet therapy regimen.

Keywords: Acute ischemic stroke; Carotid dissection; Carotid plaque; Carotid stenting; Endovascular therapy; Stroke mechanical thrombectomy.

Fig. 1

Patient with aphasia, right upper limb hyposthenia and paresthesia (NIHSS 9). Computed tomography angiography, performed at the Spoke Hospital, revealed left M1-MCA sub-occlusion (a, arrow). Patient was centralized for thrombectomy to the Hub Hospital immediately after administration of IV-FL. Digital subtraction angiography revealed a complete occlusion of the left extracranial ICA (b), with normal opacification of the previously sub-occluded vessel via retrograde anastomotic filling from the ipsilateral ophthalmic artery (c). For these reasons, intracranial thrombectomy was not carried out. Since hemodynamic impairment was observed, as poor activation of Willis’ circle (d), it was decided to perform eCAS (e). Post-procedure angiography showed good cerebral reperfusion (f, g), mTICI 2b. 90-day mRS 0