Article Text
Abstract
Introduction Tandem occlusions (TO) are a subtype of acute ischemic stroke (AIS) which involve an extracranial carotid lesion (i.e. severe carotid stenosis ≥ 70%) paired with the acute intracranial vessel occlusion. While the intracranial occlusion has a well-studied standard treatment approach with mechanical thrombectomy, the best practice for intervention of the extracranial carotid lesion, either through acute stenting or no stenting has not yet been determined. Our aim was to investigate the differences in clinical and procedural outcomes between the two approaches in patients presenting with AIS in the ASSIST registry.
Materials and Methods The ASSIST registry (an international AIS mechanical thrombectomy prospective study) was utilized to identify the subgroup of AIS patients secondary to TO who received mechanical thrombectomy (MT). The TOs were then grouped by to MT+ acute carotid stenting (MT+CAS) vs non-stenting (MT+CAT). The demographics and clinical outcomes (90-day modified Rankin Scale score (mRS)) were compared between the TO group and no TO group, and between the MT+CAS vs MT+CAT. Multivariable analyses were performed to determine the independent predictors of clinical outcomes.
Results A total of 183/1270 (14.4%) TOs were identified in ASSIST Registry. MT+CAS was performed in 83/183 (45.4%) subjects and 100/183 (54.6%) MT+CAT. There was no significant difference at baseline between the two groups in NIHSS, ASPECTS (Alberta Stroke Program Early CT Score), or vessel occluded. However, the acute stenting group were younger, lower premorbid mRS, and lower rate of atrial fibrillation. The rate of good clinical outcome (mRS 0–2) at 90-days was 70.9% in MT+CAS group vs 48.9% in MT+CAT group (p=0.001), with good clinical outcome being significantly associated with acute stenting (MT+CAS) group in multivariable analysis (OR= 2.3, CI95=1.02–5.1, adjusted for site clustering effects). There was no significant difference in mortality (4.8% MT+CAS VS 10.0% MT+CAT) or sICH (2.4% MT+CAS VS 3.0% MT+CAT) between the groups. Younger patients, lower NIHSS, and higher baseline ASPECTS scores were independent predictors of good clinical outcomes.
Conclusions In AIS patients secondary to TOs treatment with thrombectomy and acute carotid stenting is associated with improved 90-day functional outcome without an increase in sICH when compared to no acute stenting approach. On going randomized trial are on the way to confirm these findings.
Disclosures J. Olvany: None. Y. Ashouri: None. S. Miralbés: None. B. Naravetla: None. A. Spiotta: 1; C; Stryker (paid to institution), Penumbra (paid to institution), Microvention (paid to institution), Medtronic (paid to institution), RapidAI (paid to institution). 2; C; Stryker, Penumbra, Cerenovus, RapidAI, Terumo. 6; C; Participation on the Advisory Board Brain Aneurysm Foundation. C. Loehr: None. M. Martínez-Galdámez: None. R. McTaggart: None. L. Defreyne: None. P. Vega: None. P. Jenkins: 5; C; Stryker. D. Liebeskind: 2; C; Imaging core lab consulting for: Stryker, Cerenovus, Genentech, Medtronic, Rapid Medical, Vesalio. R. Gupta: 1; C; Assist Registry (PI, Stryker), RECCLAIM II Study (PI, Zoll). 2; C; Medtronic (ELEVATE Study), Penumbra (MIND Trial), Cerenovus (Membrane Study). 4; C; Vesalio, Rapid Medical. M. Möhlenbruch: 1; C; Stryker (paid to institution), Acandis, Balt, Medtronic, Microvention, Phenox. 6; C; Balt (Honoraria), Medtronic (Honoraria), Stryker (Honoraria, paid to institution). O. Zaidat: 1; C; Stryker (paid to institution), Penumbra (paid to institution), Cerenovus (paid to institution), Genentech (paid to institution), Microvention (paid to institution), Medtronic (paid to institution), Chiesi (paid to institution). 2; C; Stryker, Cerenovus, Penumbra, Medtronic.