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Effect of extracranial lesion severity on outcome of endovascular thrombectomy in patients with anterior circulation tandem occlusion: analysis of the TITAN registry
  1. Mohammad Anadani1,
  2. Alejandro Spiotta2,
  3. Ali Alawieh3,
  4. Francis Turjman4,
  5. Michel Piotin5,
  6. Henrik Steglich-Arnholm6,
  7. Markus Holtmannspötter7,
  8. Christian Taschner8,
  9. Sebastian Eiden6,
  10. Diogo C Haussen9,
  11. Raul Nogueira9,
  12. Panagiotis Papanagiotou10,
  13. Maria Boutchakova10,
  14. Adnan H Siddiqui11,
  15. Bertrand Lapergue12,
  16. Franziska Dorn13,
  17. Christophe Cognard14,
  18. Monika Killer-Oberpfalzer15,
  19. Salvatore Mangiafico16,
  20. Marc Ribo17,18,
  21. Marios-Nikos Psychogios19,
  22. Marc-Antoine Labeyrie20,
  23. Mikael Mazighi5,
  24. Alessandra Biondi21,
  25. René Anxionnat22,23,
  26. Serge Bracard22,
  27. Sébastien Richard21,
  28. Benjamin Gory22
  29. on behalf of the TITAN (Thrombectomy In TANdem Lesions) Investigators
  1. 1 Neurology and Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  2. 2 Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
  3. 3 Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4 Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lyon, Lyon, France
  5. 5 Departement of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
  6. 6 Neurology, Rigshospitalet, Copenhagen, Denmark
  7. 7 Kobenhavns Universitet Biologisk Institut, Kobenhavn, Denmark
  8. 8 Neuroradiology, Albert-Ludwigs-Universitat Freiburg, Freiburg im Breisgau, Germany
  9. 9 Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
  10. 10 Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen-Ost, Bremen, Germany
  11. 11 Departments of Neurosurgery and Radiology and Toshiba Stroke Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
  12. 12 Department of Neurology,Stroke Center, Foch Hospital, Suresnes, France
  13. 13 Department of Neuroradiology, LMU University Hospital of Munich, Munich, Germany
  14. 14 Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
  15. 15 Neurology/Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
  16. 16 Neuroradiologia Interventistica, Azienza Ospedaliero-Universitaria Careggi Firenze, florence, Italy
  17. 17 Stroke Unit. Neurology, Hospital Vall d’Hebron, Barcelona, Spain
  18. 18 Universitat Autònoma de Barcelona
  19. 19 Neuroradiology, University Medicine Goettingen, Goettingen, Germany
  20. 20 Departement of interventional neuroradiology, Hopita Lariboisiere, Paris, France
  21. 21 Neuroradiology and Endovascular Therapy, Besançon University Hospital, Besancon, France
  22. 22 Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, France
  23. 23 Université de Lorraine, Faculté de Médecine, Vandœuvre-lès-Nancy, France
  1. Correspondence to Dr Mohammad Anadani, Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC 29425, USA; anadani{at}


Introduction Endovascular treatment (EVT) for tandem occlusion (TO) of the anterior circulation is complex but effective. The effect of extracranial internal carotid artery (EICA) lesion severity on the outcomes of EVT is unknown. In this study we investigated the effect of EICA lesion severity on the outcomes of tandem occlusion EVT.

Methods A multicenter retrospective TITAN (Thrombectomy In TANdem lesions) study that included 18 international endovascular capable centers was performed. Patients who received EVT for atherosclerotic TO with or without EICA lesion intervention were included. Patients were divided into two groups based on the EICA lesion severity (high-grade stenosis (≥90% North American Symptomatic Carotid Endarterectomy Trial) vs complete occlusion). Outcome measures included the 90-day clinical outcome (modified Rankin Scale score (mRS)), angiographic reperfusion (modified Thrombolysis In Cerebral Ischemia (mTICI) at the end of the procedure), procedural complications, and intracranial hemorrhage at 24 hours follow-up.

Results A total of 305 patients were included in the study, of whom 135 had complete EICA occlusion and 170 had severe EICA stenosis. The EICA occlusion group had shorter mean onset-to-groin time (259±120 min vs 305±202 min; p=0.037), more patients with diabetes, and fewer with hyperlipidemia. With respect to the outcome, mTICI 2b–3 reperfusion was lower in the EICA occlusion group (70% vs 81%; p=0.03). The favorable outcome (90-day mRS 0–2), intracerebral hemorrhage and procedural complications were similar in both groups.

Conclusion Atherosclerotic occlusion of the EICA in acute tandem strokes was associated with a lower rate of mTICI 2b–3 reperfusion but similar functional and safety outcomes when compared with high-grade EICA stenosis.

  • stroke
  • thrombectomy
  • hemorrhage

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  • Contributors All authors have: provided a substantial contribution to the conception and design of the studies and/or the acquisition and/or the analysis of the data and/or the interpretation of the data. They have drafted the work or revised it for significant intellectual content and approved the final version of the manuscript. They agree to be accountable for all aspects of the work, including its accuracy and integrity.

  • Funding Funding for this study was provided by Stryker.

  • Competing interests MH has received honoria for consultancy and proctoring for Medtronic, Stryker, and Microvention. RN has received honoria from Stryker Neurovascular for TREVO 2 trial (Thrombectomy Revascularisation of Large Vessel Occlusions in Acute Ischemic Stroke) and DAWN Trial (Trevo and Medical Management Versus Medical Management Alone in Wake Up and Late Presenting Strokes), from Medtronic for SWIFT (Solitaire FR With the Intention for Thrombectomy) and SWIFT PRIME Trials (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke) Steering Committee, and STAR Trial core laboratory (significant), from Penumbra for 3D Separator Trial Executive Committee, and from Neuravi for ARISE-2 (Analysis of Revascularization in Ischemic Stroke With EmboTrap) Steering Committee; AHS reports grants from National Institutes of Health/NINDS/NIBIB, University at Buffalo, personal fees from Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, and Lazarus Effect, non-financial support from Codman & Shurtleff, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra, Stryker, Pulsar Vascular, MicroVention, Lazarus Effect, Blockade Medical, other from null, outside the submitted work. AS has stock from Penumbra and received honoria for consultancy and proctoring for Penumbra, and Stryker. FT has received honoria for consultancy and proctoring for Medtronic, Stryker Codman, and Balt.

  • 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.

  • Collaborators Jonathan Andrew Grossberg,Adrien Guenego, Julien Darcourt, Isabelle Vukasinovic, Anne-Christine Januel,Philippe Tall, Elisa Pomero, Jason Davies, Leonardo Renieri, Corentin Hecker,Maria Muchada Muchada, Arturo Consoli, Georges Rodesch, Emmanuel Houdart,Raymond Turner, Aquilla Turk, Imran Chaudry, Johanna Lockau, Andreas Kastrup,Rapha ël Blanc, HocineRedjem, Daniel Behme, Hussain Shallwani, Maur erChristopher, Gioia Mione, Lisa Humbertjean, Jean-Christophe Lacour, François Zhu, Anne-Laure Derelle, Romain Tonnelet, Liang Liao.

  • Patient consent for publication Not required.