Article Text

Download PDFPDF

E-140 Strategizing tandem occlusion acute stroke management based on cta
  1. S Paramasivam1,
  2. S Kumar2
  1. 1Neurosurgery, Apollo Hospitals, Chennai, India
  2. 2Neurosurgery, Apollo Hospitals, Bangalore, India


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.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.