Multicentric Experience in Distal-to-Proximal Revascularization of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection

G. Marnat; M. Bühlmann; O.F. Eker; J. Gralla; P. Machi; U. Fischer; C. Riquelme; M. Arnold; A. Bonafé; S. Jung; V. Costalat; P. Mordasini

doi:10.3174/ajnr.A5640

Abstract

BACKGROUND AND PURPOSE: Internal carotid dissection is a frequent cause of ischemic stroke in young adults. It may cause tandem occlusions in which cervical carotid obstruction is associated with intracranial proximal vessel occlusion. To date, no consensus has emerged concerning endovascular treatment strategy. Our aim was to evaluate our endovascular “distal-to-proximal” strategy in the treatment of this stroke subtype in the first large multicentric cohort.

MATERIALS AND METHODS: Prospectively managed stroke data bases from 2 separate centers were retrospectively studied between 2009 and 2014 for records of tandem occlusions related to internal carotid dissection. Atheromatous tandem occlusions were excluded. The first step in the revascularization procedure was intracranial thrombectomy. Then, cervical carotid stent placement was performed depending on the functionality of the circle of Willis and the persistence of residual cervical ICA occlusion, severe stenosis, or thrombus apposition. Efficiency, complications, and radiologic and clinical outcomes were recorded.

RESULTS: Thirty-four patients presenting with tandem occlusion stroke secondary to internal carotid dissection were treated during the study period. The mean age was 52.5 years, the mean initial NIHSS score was 17.29 ± 6.23, and the mean delay between onset and groin puncture was 3.58 ± 1.1 hours. Recanalization TICI 2b/3 was obtained in 21 cases (62%). Fifteen patients underwent cervical carotid stent placement. There was no recurrence of ipsilateral stroke in the nonstented subgroup. Twenty-one patients (67.65%) had a favorable clinical outcome after 3 months.

CONCLUSIONS: Endovascular treatment of internal carotid dissection–related tandem occlusion stroke using the distal-to-proximal recanalization strategy appears to be feasible, with low complication rates and considerable rates of successful recanalization.

ABBREVIATIONS:

ICD: internal carotid dissection
sICH: symptomatic intracranial hemorrhage

Footnotes

Gaultier Marnet, Vincent Costalat, and Pasquale Mordasini contributed equally to the study.
Disclosures: Omer Faruk Eker—UNRELATED: Payment for Development of Educational Presentations: Stryker, Medtronic*. Jan Gralla—UNRELATED: Consulting Fee or Honorarium: Medtronic, Comments: Global Principal Investigator of the STAR study and SWIFT DIRECT trial, consultant for Medtronic*; Grants/Grants Pending: SNF, Comments: research grant for MRI stroke imaging*. Urs Fischer—UNRELATED: Consultancy: Medtronic, Stryker, Comments: Advisory Board and consultancy*; Grants/Grants Pending: Medtronic, Swiss National Science Foundation, Comments: research grants for SWIFT DIRECT, ELAN, and SWITCH trials.* Marcel Arnold—UNRELATED: Board Membership: Amgen, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Pfizer, Covidien, Daiichi Sankyo, Comments: honoraria for scientific advisory boards; Grants/Grants Pending: Swiss National Science Foundation, Swiss Heart Foundation*; Payment for Lectures Including Service on Speakers Bureaus: Bayer, Covidien, Comments: honoraria for lectures. Alain Bonafé—UNRELATED: Consultancy: Stryker, Medtronic, MicroVention. Vincent Costalat—UNRELATED: Consultancy: Stryker, Medtronic, Balt, Cerenovus; Grants/Grants Pending: Stryker, Medtronic*; Payment for Development of Educational Presentations: Stryker, Medtronic, Balt Extrusion. *Money paid to the institution.