Objectives To strategize the management of major stroke secondary to tandem occlusions of extracranial ICA and Intracranial ICA/MCA based on the collateral assessment in the pre-procedure CTA.
Methods In a retrospective analysis of our Stroke Thrombectomy database (n = 85), treated between August 2016 to December 2018 we identified 15 patients who presented with tandem occlusion. 13 were atherosclerotic disease and 2 were carotid dissection along with middle cerebral artery or distal ICA occlusion. All patients had pre-procedure CT angiogram, along with the primary pathology, collaterals comprising of Acom and Pcom arteries and their caliber was analyzed. All except 3 patients were treated with balloon angioplasty. 4 patients had carotid stenting. The decision on emergent stenting was based on the algorithm shown in Image attachment. Stenting is done following Bolus GP2B3A inhibitor followed by infusion for 6 hours and Asprin and Plavix given through NG tube. Successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2b or 3 and neurological improvement is defined by ≥ 8 point reduction of National Institutes of Health Stroke Scale (NIHSS) score at 7 days and an improved modified Rankin Scale (mRS ≤ 2) score at 90 days.
Results Overall, 93% had TICI 2b/3 signifying successful recanalization. 46.6% had a reduction in the NIHSS score by ≥ 8 points at 1 week. 60% had a good outcome with a mRS ≤ 2. Mortality was 12.5% (n = 2) with 1deaths due to massive hemorrhage and 1 death due to cardiac cause.
Conclusions Major Strokes due to tandem occlusion of ICA and ICA/MCA can be treated successfully with lesser morbidity and mortality if strategized based on the understanding of collateral circulation based on pre-procedure CT angiogram. The number of stenting can be minimized and reserved for only those patients with a poor flow in the proximal ICA and poor collateral circulation and those with carotid dissection.
Disclosures S. Paramasivam: None. S. Kumar: None.
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