Vol 54, No 5 (2020)
Research Paper
Published online: 2020-07-23

open access

Page views 1398
Article views/downloads 550
Get Citation

Connect on Social Media

Connect on Social Media

Effectiveness and safety of ICA stenting in conjunction with mechanical thrombectomy (antegrade approach) in acute ischaemic stroke patients due to tandem occlusion

Michał Sojka1, Maciej Szmygin1, Krzysztof Pyra1, Piotr Tarkowski2, Piotr Luchowski3, Joanna Wojczal3, Anna Drelich-Zbroja1, Tomasz Jargiełło1
Pubmed: 32700307
Neurol Neurochir Pol 2020;54(5):426-433.


Aim of study. We investigated the effectiveness and safety of an antegrade approach consisting of emergency ICA stenting in conjunction with mechanical thrombectomy (MT) in a one-stage procedure as a treatment for Tandem Occlusion (TO).

Clinical rationale for study. We here describe our experience in the treatment of TO with an antegrade approach with long-term results. We also discuss the advantages and drawbacks of this treatment modality with special attention to possible haemorrhagic complications that can be encountered in patients with ischaemic stroke who receive antiplatelet treatment. We believe that our study adds to the limited number of reports on this topic.

Materials and methods. We selected 34 patients diagnosed with acute ischaemic stroke due to ICA and ipsilateral intracranial occlusion treated with ICA stenting in conjunction with MT. We analysed the short- and long-term results as well as investigating complications with special regard to haemorrhagic transformation
associated with the need for antiplatelet treatment after stent implantation in patients after acute ischaemic stroke treatment.

Results. A favourable angiographic outcome was defined as mTICI 2b–3. This was achieved in 33/34 patients (97%). On average, NIHSS at 24 hours after the procedure was 8.5 ± 7, which indicates a significant clinical improvement. Four cases of symptomatic ICH were observed (11.8%). One re-occlusion in stent was noted. At three-month follow-up, mRS scores were 0 in 11 (34.3%), 1 in 5 (16%), 2 in 1 (3%), 3 in 3 (9.3%), 4 in 3 (9.3%), and 5 in 2 (6%) patients. Seven patients did not survive (22%). Overall, a favourable outcome (mRS 0–2) was achieved in 17/34 patients (50%). The final mortality rate was 26.5% (9/34 patients).

Conclusions and clinical implications. We conclude that an antegrade approach is a feasible and effective method for treating acute TO stroke, giving the patient the chance to regain his or her full independence in everyday life, with low overall complication and final mortality rates.

Article available in PDF format

View PDF Download PDF file


  1. Assis Z, Menon BK, Goyal M, et al. ESCAPE Trialists. Acute ischemic stroke with tandem lesions: technical endovascular management and clinical outcomes from the ESCAPE trial. J Neurointerv Surg. 2018; 10(5): 429–433.
  2. Papanagiotou P, Haussen DC, Turjman F, et al. TITAN Investigators. Carotid Stenting With Antithrombotic Agents and Intracranial Thrombectomy Leads to the Highest Recanalization Rate in Patients With Acute Stroke With Tandem Lesions. JACC Cardiovasc Interv. 2018; 11(13): 1290–1299.
  3. Rubiera M, Ribo M, Delgado-Mederos R, et al. Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke. 2006; 37(9): 2301–2305.
  4. Akpinar CK, Gürkaş E, Aytac E. Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting may be a better option in acute tandem occlusions. Interv Neuroradiol. 2017; 23(4): 405–411.
  5. Maus V, Borggrefe J, Behme D, et al. Order of Treatment Matters in Ischemic Stroke: Mechanical Thrombectomy First, Then Carotid Artery Stenting for Tandem Lesions of the Anterior Circulation. Cerebrovasc Dis. 2018; 46(1-2): 59–65.
  6. Behme D, Knauth M, Psychogios MN. Retriever wire supported carotid artery revascularization (ReWiSed CARe) in acute ischemic stroke with underlying tandem occlusion caused by an internal carotid artery dissection: Technical note. Interv Neuroradiol. 2017; 23(3): 289–292.
  7. Hemphill JC, Greenberg SM, Anderson CS, et al. American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015; 46(7): 2032–2060.
  8. Błażejewska-Hyżorek B, Czernuszenko A, Członkowska A, et al. Ischemic stroke guidelines. Polski Przegląd Neurologiczny. 2019; 15(Supl. A): 53–55.
  9. Kernan W, Ovbiagele B, Black H, et al. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. Stroke. 2014; 45(7): 2160–2236.
  10. Sadeh-Gonik U, Tau N, Friehmann T, et al. Thrombectomy outcomes for acute stroke patients with anterior circulation tandem lesions: a clinical registry and an update of a systematic review with meta-analysis. Eur J Neurol. 2018; 25(4): 693–700.
  11. Zhu F, Anadani M, Labreuche J, et al. Impact of Antiplatelet Therapy During Endovascular Therapy for Tandem Occlusions. Stroke. 2020; 51(5): 1522–1529.
  12. Sedat J, Chau Y, Gaudard J, et al. Administration of eptifibatide during endovascular treatment of ruptured cerebral aneurysms reduces the rate of thromboembolic events. Neuroradiology. 2015; 57(2): 197–203.
  13. Mpotsaris A, Kabbasch C, Borggrefe J, et al. Stenting of the cervical internal carotid artery in acute stroke management: The Karolinska experience. Interv Neuroradiol. 2017; 23(2): 159–165.
  14. Mpotsaris A, Bussmeyer M, Buchner H, et al. Clinical outcome of neurointerventional emergency treatment of extra- or intracranial tandem occlusions in acute major stroke: antegrade approach with wallstent and solitaire stent retriever. Clin Neuroradiol. 2013; 23(3): 207–215.
  15. Zhu F, Bracard S, Anxionnat R, et al. Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Strokes Treated by Thrombectomy: A Review of the TITAN Collaboration. Front Neurol. 2019; 10: 206.
  16. Gory B, Haussen DC, Piotin M, et al. Thrombectomy In TANdem lesions (TITAN) investigators. Impact of intravenous thrombolysis and emergent carotid stenting on reperfusion and clinical outcomes in patients with acute stroke with tandem lesion treated with thrombectomy: a collaborative pooled analysis. Eur J Neurol. 2018; 25(9): 1115–1120.
  17. Blassiau A, Gawlitza M, Manceau PF, et al. Mechanical Thrombectomy for Tandem Occlusions of the Internal Carotid Artery-Results of a Conservative Approach for the Extracranial Lesion. Front Neurol. 2018; 9: 928.
  18. Bracard S, Ducrocq X, Mas JL, et al. THRACE investigators. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016; 15(11): 1138–1147.
  19. Spiotta AM, Lena J, Vargas J, et al. Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke. J Neurointerv Surg. 2015; 7(3): 164–169.
  20. Lockau H, Liebig T, Henning T, et al. Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology. 2015; 57(6): 589–598.
  21. Nesbit GM, Clark WM, O'Neill OR, et al. Intracranial intraarterial thrombolysis facilitated by microcatheter navigation through an occluded cervical internal carotid artery. J Neurosurg. 1996; 84(3): 387–392.
  22. Son S, Choi DS, Oh MK, et al. Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience. J Neurointerv Surg. 2015; 7(4): 238–244.
  23. Emiru T, Chaudhry SA, Qureshi AI. A survey of preprocedural intubation practices for endovascular treatment of acute ischemic stroke. J Vasc Interv Neurol. 2014; 7(3): 30–33.
  24. Brinjikji W, Murad MH, Rabinstein AA, et al. Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2015; 36(3): 525–529.
  25. Brinjikji W, Pasternak J, Murad MH, et al. Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis. Stroke. 2017; 48(10): 2784–2791.
  26. Abou-Chebl A, Yeatts SD, Yan B, et al. Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial. Stroke. 2015; 46(8): 2142–2148.
  27. Zhang Yu, Jia Lu, Fang F, et al. General Anesthesia Versus Conscious Sedation for Intracranial Mechanical Thrombectomy: A Systematic Review and Meta-analysis of Randomized Clinical Trials. J Am Heart Assoc. 2019; 8(12): e011754.
  28. Shpak M, Ramakrishnan A, Nadasdy Z, et al. Higher Incidence of Ischemic Stroke in Patients Taking Novel Oral Anticoagulants. Stroke. 2018; 49(12): 2851–2856.
  29. Fernandes L, Sargento-Freitas J, Milner J, et al. Ischemic stroke in patients previously anticoagulated for non-valvular atrial fibrillation: Why does it happen? Rev Port Cardiol. 2019; 38(2): 117–124.

Neurologia i Neurochirurgia Polska