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Review
Management of tandem occlusions in acute ischemic stroke – intracranial versus extracranial first and extracranial stenting versus angioplasty alone: a systematic review and meta-analysis
  1. Mitchell P Wilson1,
  2. Mohammad H Murad2,
  3. Timo Krings3,
  4. Vitor M Pereira3,
  5. Cian O’Kelly4,
  6. Jeremy Rempel1,
  7. Christopher A Hilditch3,
  8. Waleed Brinjikji3,5
  1. 1Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
  2. 2Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
  3. 3Joint Department of Medical Imaging, Neuroradiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
  4. 4Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
  5. 5Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Mitchell P Wilson, Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta T6G2B7, Canada; mitch.wilson{at}ualberta.ca

Abstract

Background Optimal technical approaches of large-vessel anterior circulation acute ischemic strokes with concomitant extracranial internal carotid artery tandem occlusions is controversial.

Purpose This systematic review and meta-analysis evaluates: the overall outcomes of patients with tandem occlusions treated with second-generation mechanical thrombectomy devices; differences in outcomes of extracranial versus intracranial first approaches; and differences in outcomes of extracranial stenting at time of procedure versus angioplasty alone.

Methods MEDLINE, EMBASE, and the Web of Science was searched through September 2017 for studies evaluating patients presenting with acute tandem occlusions of the extracranial ICA and intracranial ICA, and/or proximal MCA treated with second-generation mechanical thrombectomy devices. Outcomes were pooled across studies using the random-effects model and expressed as cumulative incidence (event rate) and 95% CI.

Results Thirty-three studies were included in analysis. Overall mRS≤0–2 at 90 days was 47% (95% CI 42% to 51%). No statistical difference was seen in 90-day mRS≤0–2 for patients treated with extracranial versus intracranial first approaches, 53% (95% CI 44% to 61%) vs 49% (95% CI 44% to 57%) (P=0.58). No statistical difference was seen in 90-day mRS≤0–2 for patients treated with extracranial stenting versus angioplasty alone, 49% (95% CI 42% to 56%) vs 49% (95% CI 33% to 65%) (P=0.39). No other statistical differences in outcome or safety were identified.

Conclusions Nearly half of all tandem occlusion patients treated with mechanical thrombectomy have good neurological outcomes. No statistical differences in outcome are identified between extracranial first versus intracranial first approaches, nor extracranial stenting versus angioplasty alone.

  • stroke
  • thrombectomy
  • stent
  • thrombolysis
  • technique

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Footnotes

  • Contributors MPW and WB conceptualized and designed the project. MPW reviewed the articles and collected the data. MHM analyzed the data. All authors contributed to data interpretation, write-up, editing, and revisions of the final manuscript. All authors have contributed to production of the final version of this manuscript.

  • Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

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

  • Data sharing statement Additional data from this project can be acquired by contacting the corresponding author at mitch.wilson@ualberta.ca

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