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Original research
Endovascular therapy with or without intravenous thrombolysis in acute stroke with tandem occlusion
  1. Mohammad Anadani1,2,
  2. Gaultier Marnat3,
  3. Arturo Consoli4,5,
  4. Panagiotis Papanagiotou6,7,
  5. Raul G Nogueira8,
  6. Alejandro M Spiotta9,
  7. Romain Bourcier10,
  8. Maeva Kyheng11,
  9. Julien Labreuche11,
  10. Adnan H Siddiqui12,
  11. Marc Ribo13,
  12. Adam de Havenon14,
  13. Urs Fischer15,
  14. Igor Sibon16,
  15. Cyril Dargazanli17,
  16. Caroline Arquizan18,
  17. Christophe Cognard19,
  18. Jean Marc Olivot20,
  19. René Anxionnat21,22,
  20. Gérard Audibert23,
  21. Mikael Mazighi24,
  22. Raphael Blanc24,
  23. Bertrand Lapergue25,
  24. Sébastien Richard26,
  25. Benjamin Gory21,22,
  26. TITAN (Thrombectomy In TANdem lesions) Investigators
  27. Endovascular Treatment in Ischemic Stroke (ETIS) Investigators
      1. 1Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
      2. 2Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
      3. 3Department of Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
      4. 4Department of Diagnostic and Interventional Neuroradiology, Hospital Foch, Suresnes, France
      5. 5Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
      6. 6Klinikum Bremen-Mitte gGmbH, Bremen, Germany
      7. 7National and Kapodistrian University of Athens - Aretaiio Hospital, Athens, Greece
      8. 8Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
      9. 9Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
      10. 10Department of Neuroradiology, Nantes University Hospital, Nantes, France
      11. 11Université Lille, CHU Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, Université de Lille, Lille, Hauts-de-France, France
      12. 12Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
      13. 13Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
      14. 14Department of Neurology, University of Utah, Salt Lake City, Utah, USA
      15. 15Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
      16. 16Department of Neurology, Stroke Unit, Bordeaux University Hospital, Bordeaux, France
      17. 17Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
      18. 18Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
      19. 19Department of Diagnostic and Therapeutic Neuroradiology, Toulouse University Hospital, Toulouse, France
      20. 20Department of Neurology, Toulouse University Hospital, Toulouse, France
      21. 21Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
      22. 22Université de Lorraine, IADI, INSERM U1254, Nancy, France
      23. 23Department of Anesthesiology and Surgical Intensive Care, Université de Lorraine, CHRU-Nancy, Nancy, France
      24. 24Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
      25. 25Department of Neurology, Stroke Unit, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
      26. 26Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, Nancy, France
      1. Correspondence to Dr Benjamin Gory, Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Hôpital Central, 54000 Nancy, France; benjagory{at}


      Background Endovascular therapy (EVT) is effective and safe in patients with tandem occlusion. The benefit of intravenous thrombolysis (IVT) prior to EVT in acute tandem occlusion is debatable.

      Objective To compare EVT alone with EVT plus IVT in patients with acute ischemic stroke due to anterior circulation tandem occlusions.

      Methods This is an individual patient pooled analysis of the Thrombectomy In TANdem lesions (TITAN) and Endovascular Treatment in Ischemic Stroke (ETIS) Registries. Patients were divided into two groups based on prior IVT treatment: (1) IVT+ group, which included patients who received IVT prior to EVT, (2) IVT− group, which included patients who did not receive IVT prior to EVT. Propensity score (inverse probability of treatment weighting (IPTW)) was used to reduce baseline between-group differences. The primary outcome was favorable outcome—that is, modified Rankin Scale (mRS) score 0 to 2 at 90 days.

      Results Overall, 602 consecutive patients with an acute stroke with tandem occlusion were included (380 and 222 in the bridging therapy and EVT alone groups, respectively). Onset to imaging time was shorter in the IVT+ group (median 103 vs 140 min). In contrast, imaging to puncture time was longer in the IVT+ group (median 107 vs 91 min). In IPTW analysis, the IVT+ group had higher odds of favorable outcome, excellent outcome (90-day mRS score 0–1), and successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b/3 at the end of EVT). There was no difference in the risk of significant hemorrhagic complications between groups. In secondary analysis of patients treated with acute cervical internal carotid artery stenting, bridging therapy was associated with higher odds of favorable outcome and lower odds of mortality at 90 days.

      Conclusions Our results suggest that bridging therapy in patients with acute ischemic stroke due to anterior tandem occlusion is safe and may improve functional outcome, even in the setting of acute cervical internal carotid artery stenting during EVT.

      • stroke
      • hemorrhage
      • thrombectomy

      Data availability statement

      The data that support the findings of this study are available from the corresponding author upon reasonable request.

      Statistics from

      Data availability statement

      The data that support the findings of this study are available from the corresponding author upon reasonable request.

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      • Collaborators TITAN (Thrombectomy In TANdem lesions) Investigators:Francis Turjman, Michel Piotin, Henrik Steglich-Arnholm, Markus Holtmannspötter, Christian Taschner, Sebastian Eiden, Diogo C. Haussen, Muhammad Waqas, Maria Boutchakova, Franziska Dorn, Monika Killer-Oberpfalzer, Salvatore Mangiafico, Marios N. Psychogios, Marc-Antoine Labeyrie, Alessandra Biondi, Serge Bracard, Jonathan Andrew Grossberg, Adrien Guenego, Julien Darcourt, Isabelle Vukasinovic, Elisa Pomero, Jason Davies, Leonardo Renieri, Corentin Hecker, Maria Muchada Muchada, Arturo Consoli, Georges Rodesch, Emmanuel Houdart, Johanna Lockau, Andreas Kastrup, Hocine Redjem, Daniel Behme, Hussain Shallwani, Maurer Christopher, Gioia Mione, Lisa Humbertjean, Nolwenn Riou-Comte, François Zhu, Anne-Laure Derelle, Liang Liao.Endovascular Treatment in Ischemic Stroke (ETIS) Investigators:Fondation Adolphe de Rothschild: Michel Piotin, Raphael Blanc, Hocine Redjem, Simon Escalard, Jean-Philippe Desilles, Gabriele Ciccio, Stanislas Smajda, Mikael Mazighi, Mikael Obadia, Candice Sabben, Ovide Corabianu, Thomas de Broucker, Didier Smadja, Sonia Alamowitch, Olivier Ille, Eric Manchon, Pierre-Yves Garcia, Guillaume Taylor, Malek Ben Maacha.Hôpital Foch: Adrien Wang, Serge Evrard, Maya Tchikviladze, Nadia Ajili, Bertrand Lapergue, David Weisenburger, Lucas Gorza, Oguzhan Coskun, Arturo Consoli, Federico Di Maria, Georges Rodesh, Morgan Leguen, Julie Gratieux, Fernando Pico, Haja Rakotoharinandrasana, Philippe Tassan, Roxanna Poll, Sylvie Marinier.CHU Bordeaux: Gaultier Marnat, Florent Gariel, Xavier Barreau, Jérôme Berge, Louis Veunac, Patrice Menegon, Igor Sibon, Ludovic Lucas, Stéphane Olindo, Pauline Renou, Sharmila Sagnier, Mathilde Poli, Sabrina Debruxelles, Thomas Tourdias, Jean-Sebastien Liegey.CHU Nantes: Romain Bourcier, Lili Detraz, Benjamin Daumas-Duport, Pierre-Louis Alexandre, Monica Roy, Cédric Lenoble, Vincent L’allinec, Jean-Baptiste Girot, Hubert Desal.CHRU-Nancy: Benjamin Gory, Isabelle Costa, Serge Bracard, René Anxionnat, Marc Braun, Anne-Laure Derelle, Romain Tonnelet, Liang Liao, François Zhu, Emmanuelle Schmitt, Sophie Planel, Sébastien Richard, Lisa Humbertjean, Gioia Mione, Jean-Christophe Lacour, Nolwenn Riou-Comte, Gabriela Hossu, Marine Beaumont, Mitchelle Bailang, Gérard Audibert, Marie Reitter, Agnès Masson, Lionel Alb, Adriana Tabarna, Marcela Voicu, Iona Podar, Madalina Brezeanu.CHU Montpellier: Vincent Costalat, Caroline Arquizan, Cyril Dargazanli, Grégory Gascou, Pierre-Henri Lefèvre, Imad Derraz, Carlos Riquelme, Nicolas Gaillard, Isabelle Mourand, Lucas Corti.

      • Contributors Substantial contributions to the conception or design of the work: MA, PP; RGN; AMS, AdH, BG, GM. Acquisition, analysis, and interpretation of the data for the work: MK, JL, AC, RBo, AHS, MR, IS, CD, CA, CC, JMO, RA, GA,GM, MM, RBl, BL, SR. Drafting the work or revising it critically for important intellectual content: MA; RGN; AdH, BG, UF.

      • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      • Competing interests AMS reports support from Penumbra, Stryker, Medtronic; and consulting fees from: Terumo, Stryker, Penumbra, Siemens. BL reports grants from Stryker, Penumbra, and Microvention. MM reports personal fees from Acticor Biotech, Air liquide, Amgen, and Boerhinger. RGN: principal investigator, Stryker Neurovascular (DAWN trial (no compensation), Trevo-2 trial), Cerenovus/Neuravi (ENDOLOW trial, no compensation); consultant to Stryker Neurovascular; steering committee member, Stryker Neurovascular(no compensation), Medtronic (SWIFT trial, SWIFT Prime trial (no compensation)), Cerenovus/Neuravi (ARISE-2 trial, no compensation); angiographic core lab, Medtronic (STAR trial); executive committee member, Penumbra (no compensation); physician advisory board, Cerenovus/Neuravi, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Allm Inc.(no compensation), Viz-AI (stock options). AHS: financial interest/investor/stock options/ownership: Amnis Therapeutics, Apama Medical,Blink TBI, Inc., Buffalo Technology Partners, Inc., Cardinal Health, Cerebrotech Medical Systems, Inc., Claret Medical, Cognition Medical, Endostream Medical, Ltd., Imperative Care, International Medical Distribution Partners, Rebound Therapeutics Corp., Silk Road Medical, StimMed, Synchron, Three Rivers Medical, Inc., Viseon Spine, Inc; consultant/advisory board: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA, Inc., Cerebrotech Medical Systems, Inc., Cerenovus, Claret Medical, Corindus, Inc., Endostream Medical, Ltd., Guidepoint 15Global Consulting, Imperative Care, Integra, Medtronic, MicroVention, Northwest University—DSMB Chair for HEAT Trial, Penumbra, Rapid Medical, Rebound Therapeutics Corp., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc.,VasSol, W.L. Gore & Associates; national PI/steering committees: Cerenovus LARGE Trial and ARISE II Trial, Medtronic SWIFTPRIME and SWIFT DIRECT Trials, MicroVention FRED Trial & CONFIDENCE Study, MUSC POSITIVE Trial,Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial; principal investigator: Cummings Foundation grant.

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

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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