Article Text

Download PDFPDF
Original research
Management and outcome of patients with acute ischemic stroke and tandem carotid occlusion in the ESCAPE-NA1 trial
  1. Martha Marko1,2,
  2. Petra Cimflova3,
  3. Alexandre Y Poppe4,5,
  4. Nima Kashani6,
  5. Nishita Singh7,
  6. Johanna Ospel8,9,
  7. Arnuv Mayank3,
  8. Brian van Adel10,
  9. Ryan A McTaggart11,
  10. Raul G Nogueira12,
  11. Andrew M Demchuk13,
  12. Jeremy L Rempel14,
  13. Manish Joshi7,
  14. Charlotte Zerna2,
  15. Bijoy K Menon13,
  16. Michael Tymianski15,
  17. Michael D Hill13,
  18. Mayank Goyal16,
  19. Mohammed A Almekhlafi2
  20. on behalf of the ESCAPE-NA1 investigators
  1. 1Department of Neurology, Medical University of Vienna, Wien, Austria
  2. 2Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  3. 3Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  4. 4Department of Neurosciences, Université de Montréal, Montreal, Québec, Canada
  5. 5Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
  6. 6Neuroradiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  7. 7Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
  8. 8Department of Radiology, University Hospital Basel, Basel, Switzerland
  9. 9University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  10. 10Neurosurgery, McMaster University Department of Medicine, Hamilton, Ontario, Canada
  11. 11Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
  12. 12Emory University School of Medicine, Grady Memorial Hospital Corp, Atlanta, Georgia, USA
  13. 13Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  14. 14Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
  15. 15NoNO, Toronto, Ontario, Canada
  16. 16Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  1. Correspondence to Dr Mohammed A Almekhlafi, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada; mohammed.almekhlafi1{at}ucalgary.ca

Abstract

Background The optimal treatment and prognosis for stroke patients with tandem cervical carotid occlusion are unclear. We analyzed outcomes and treatment strategies of tandem occlusion patients in the ESCAPE-NA1 trial.

Methods ESCAPE-NA1 was a multicenter international randomized trial of nerinetide versus placebo in 1105 patients with acute ischemic stroke who underwent endovascular treatment. We defined tandem occlusions as complete occlusion of the cervical internal carotid artery (ICA) on catheter angiography, in addition to a proximal ipsilateral intracranial large vessel occlusion. Baseline characteristics and outcome parameters were compared between patients with tandem occlusions versus those without, and between patients with tandem occlusion who underwent ICA stenting versus those who did not. The influence of tandem occlusions on functional outcome was analyzed using multivariable regression modeling.

Results Among 115/1105 patients (10.4%) with tandem occlusions, 62 (53.9%) received stenting for the cervical ICA occlusion. Of these, 46 (74.2%) were stented after and 16 (25.8%) before the intracranial thrombectomy. A modified Rankin Score (mRS) of 0–2 at 90 days was achieved in 82/115 patients (71.3%) with tandem occlusions compared with 579/981 (59.5%) patients without tandem occlusions. Tandem occlusion did not impact functional outcome in the adjusted analysis (OR 1.5, 95% CI 0.95 to 2.4). Among the subgroup of patients with tandem occlusion, cervical carotid stenting was not associated with different outcomes compared with no stenting (mRS 0–2: 75.8% vs 66.0%, adjusted OR 2.0, 95% CI 0.8 to 5.1).

Conclusions Tandem cervical carotid occlusion in patients with acute large vessel stroke did not lower the odds of good functional outcome in our study. Functional outcomes were similar irrespective of the management of the cervical ICA occlusion (stenting vs not stenting).

  • stroke
  • thrombectomy

Data availability statement

Access to data from the ESCAPE-NA1 trial supporting these findings is planned for the future but is not currently publicly available

Statistics from Altmetric.com

Data availability statement

Access to data from the ESCAPE-NA1 trial supporting these findings is planned for the future but is not currently publicly available

View Full Text

Footnotes

  • Twitter @martha_marko, @nimakashani, @CharlotteZerna, @mihill68, @AlmekhlafiMa

  • Contributors MM and MA contributed to the conceptualization and statistical analysis and drafted the manuscript. PC, AYP, NK, NS, JO, AM, MDH and MG contributed to data acquisition, conceptualization, analysis and critical revision of the manuscript. The remaining authors contributed to data acquisition, data interpretation and critical revision of the manuscript. All authors approved the final version of the manuscript.

  • Funding The ESCAPE-NA1 trial was funded by the Canadian Institutes for Health Research, Alberta Innovates, and NoNO Inc.

  • Competing interests AYP: Research grant from Stryker for EASI-TOC study, PI of EASI-TOC study. JMO: funds from the University of Basel Research Foundation, Julia Bangerter Rhyner Foundation, Freiwillige Akademische Gesellschaft Basel. RGN: fees/compensation from Stryker, Medtronic, Cerenovus/Neuravi, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Brainomix, Viz.ai, Corindus Vascular Robotics, Vesalio, and Ceretrieve; member of the Physician Advisory Board for Cerenovus/Neuravi. ADM: grants from NoNO; honoraria from Medtronic; patent Circle NVI. BKM: shares in Circle NVI; patent for systems of triage in acute stroke. MT: CEO of NoNO; patents owned by NoNO. MDH: grants from Canadian Institutes for Health Research, Alberta Innovates, NoNO, Heart & Stroke Foundation of Canada, National Institutes of Neurological Disorders and Stroke, Covidien, Boehringer-Ingleheim, Stryker, and Medtronic; fees from Merck; patent for systems of acute stroke diagnosis; stock in Calgary Scientific. MG: personal fees from Mentice, Medtronic, Microvention, Stryker; patent for systems of acute stroke diagnosis. BKM holds a patent on systems of triage in acute stroke and stock ownership in Circle Neurovascular Inc. MG is a consultant for Medtronic, Stryker, Microvention, GE Healthcare, and Mentice. MDH reports grants from CIHR during the conduct of the study, grants from Medtronic, and grants from NoNO Inc outside the submitted work. In addition, he has a patent to US Patent Office number: 62/086,077 issued and licensed, and Director, Board of Circle Neurovascular, Director, Board of the Canadian Neuroscience Federation, and Director, Board of the Canadian Stroke Consortium.

  • 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.

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.