Endovascular management of extracranial occlusions at the hyperacute phase of stroke with tandem occlusions

M-A Labeyrie; C Ducroux; V Civelli; P Reiner; E Cognat; A Aymard; A Bisdorff; J-P Saint-Maurice; E Houdart

doi:10.1016/j.neurad.2017.10.003

Endovascular management of extracranial occlusions at the hyperacute phase of stroke with tandem occlusions

J Neuroradiol. 2018 May;45(3):196-201. doi: 10.1016/j.neurad.2017.10.003. Epub 2017 Nov 11.

Authors

M-A Labeyrie¹, C Ducroux², V Civelli³, P Reiner³, E Cognat⁴, A Aymard⁴, A Bisdorff⁴, J-P Saint-Maurice⁴, E Houdart⁴

Affiliations

¹ Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France; EA 7334 REMES (MAL, EH), université de Paris 7, 75013 Paris, France. Electronic address: marc-antoine.labeyrie@aphp.fr.
² Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
³ Department of Neurology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
⁴ Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France; EA 7334 REMES (MAL, EH), université de Paris 7, 75013 Paris, France.

PMID: 29132938
DOI: 10.1016/j.neurad.2017.10.003

Abstract

Background and purpose: The management of cervical artery occlusions in hyperacute stroke with tandem cervical/intracranial occlusions has not yet become standardized, especially when the circle of Willis is effective.

Methods: We retrospectively analyzed the safety and accuracy of current approaches to manage the cervical occlusion in consecutive patients with tandem occlusions addressed for intracranial mechanical thrombectomy (MT) in our department from January 2012 to May 2017. The different approaches that could be performed in a same patient during the same procedure or hospitalization were analyzed separately.

Results: We reported 64 approaches to manage the cervical occlusion in 49 patients with tandem occlusion (14% of MT): medical treatment alone in 16/64 (25%), stenting/angioplasty in 16/64 (25%), occlusion with coils in 12/64 (19%), angioplasty alone in 9/64 (14%), stent-retriever in 8/64 (12%), and/or thromboaspiration in 3/64 (5%). Early ipsilateral embolic recurrence occurred after 9/64 (14%) of them. It was strongly associated with the presence of a cervical intraluminal thrombus (P=0.001) and was then lower after occlusion with coils and stent-retriever compared to medical treatment alone and thromboaspiration (P=0.002). Occlusion with coils had a lower rate of radiological intracranial hemorrhage at 48-hour compared to other approaches (P=0.009). The 3-month rates of favorable outcome (P=0.806) and mortality (P=0.878) were similar. One delayed stroke was imputable to an occlusion with coils, for a median (Q1-Q3) follow-up of 10 (3-20) months.

Conclusions: Cervical occlusion with coils and thrombectomy with stent-retrievers may be relevant to prevent early embolic recurrence in cervical occlusions with intraluminal thrombus. Stent-retrievers should be further assessed as a first-line approach, since delayed stroke may occur following occlusion with coils. Medical treatment alone may be sufficient when no cervical intraluminal thrombus is present, the Willis polygon is effective, and the cervical occlusion can be crossed easily to perform the intracranial thrombectomy.

Keywords: Ischemic stroke; Mechanical thrombectomy; Tandem occlusion.

MeSH terms

Aged
Brain Ischemia / complications*
Brain Ischemia / diagnostic imaging
Carotid Stenosis / surgery*
Disease Management
Endovascular Procedures / methods*
Female
Humans
Male
Mechanical Thrombolysis / methods
Middle Aged
Retrospective Studies
Stroke / complications*
Stroke / diagnostic imaging
Treatment Outcome