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Acute ischemic stroke with tandem lesions: technical endovascular management and clinical outcomes from the ESCAPE trial
  1. Zarina Assis1,
  2. Bijoy K Menon1,
  3. Mayank Goyal1,
  4. Andrew M Demchuk1,
  5. Jai Shankar2,
  6. Jeremy L Rempel3,
  7. Daniel Roy4,
  8. Alexander Y Poppe5,
  9. Victor Yang6,
  10. Cheemun Lum7,
  11. Dar Dowlatshahi8,
  12. John Thornton9,
  13. Hana Choe10,
  14. Paul A Burns11,
  15. Donald F Frei12,
  16. Blaise W Baxter13,
  17. Michael D Hill1,14
  18. for the ESCAPE Trialists
  1. 1Department of Clinical Neurosciences and Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
  2. 2Department of Radiology, Dalhousie University, Halifax, Canada
  3. 3Department of Radiology, University of Alberta, Edmonton, Canada
  4. 4Department of Radiology, CHUM, University of Montreal, Montreal, Canada
  5. 5Department of Neurosciences, CHUM, University of Montreal, Montreal, Canada
  6. 6Department of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Canada
  7. 7Department of Radiology, University of Ottawa, The Ottawa Hospital, Ottawa, Canada
  8. 8Medicine (Neurology), University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
  9. 9Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
  10. 10Department of Clinical Neurosciences, The Neurosciences Institute, Abington Memorial Hospital, Abington, USA
  11. 11Department of Neuroradiology, Royal Victoria Hospital, Belfast, UK
  12. 12Department of Neuroradiology, Colorado Neurological Institute, Engelwood, Colorado, USA
  13. 13Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga, USA
  14. 14Department of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Canada
  1. Correspondence to Dr Michael D Hill, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, T2N 2T9, Canada; michael.hill{at}ucalgary.ca
  • CL is deceased

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.

Trialregistration number NCT01778335.

  • stroke
  • endovascular treatment
  • randomized controlled trial
  • carotid occlusion

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Footnotes

  • Contributors All the authors of this manuscript have given substantial contributions to the conception or design of the work; the acquisition, analysis, and interpretation of data for the work; drafting the work and revising it critically for important intellectual content; final approval of the version to be published; and have given agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The ESCAPE trial was an academic trial funded by a consortium including Medtronic, the University of Calgary (Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Calgary Stroke Program), Alberta Innovates, the Heart & Stroke Foundation of Canada, the Canadian Institutes for Health Research and Alberta Health Services.

  • 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.

  • Ethics approval Ethics board of each 22 sites enrolled in ESCAPE trial.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement None declared.

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