Endovascular treatment for acute ischemic stroke due to the anterior circulation tandem occlusion

doi:10.3969/j.issn.1672-6731.2020.11.011

Abstract

Abstract:

Objective To investigate the availability and safety of distal mechanical embolization combined with simultaneous carotid stenting for acute ischemic stroke due to anterior circulation tandem occlusion of large intracranial vessels and carotid artery. Methods Ten patients with anterior circulation intracranial artery occlusion combined with severe stenosis or occlusion at the beginning of ipsilateral internal carotid artery were selected in Department of Neurosurgery, the First Affiliated Hospital of Harbin Medical University from January to December 2019. All patients were treated with balloon dilation for the lesion at the beginning of the artery. The distal end of the catheter was removed through the guide catheter, and then the carotid stent implantation was performed. Immediately after surgery, modified Thrombolytic in Cerebral Infarction (mTICI) was used to evaluate vascular recanalization. The National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the degree of neurological deficit 24 h after surgery, and the modified Rankin Scale (mRS) was used to evaluate the prognosis of 90 d after surgery, and recorded symptomatic intracranial hemorrhage, non-symptomatic intracranial hemorrhage, and surgical complications. Results All patients completed the surgery. The immediate postoperative intracranial vessel mTICI was 2b grade in 5 cases, 3 grade in 3 cases, 2a grade in one case, and 0 grade in one case. The revascularization rate was 8/10. Of the 8 patients with successful revascularization, one patient (12.50%) occurred reocclusion the extracranial segment of the internal carotid artery at 7 d after surgery, but the clinical symptoms were not worsen. Six patients had a NIHSS score ≥ 4 points which were lower than baseline 24 h after surgery, and their symptoms improved significantly; 90 d postoperative mRS score was 0 in 2 cases, 1 in one case, 2 in one case, 3 in 4 cases, 4 in one case, and 6 in one case (died). The rate of good was 4/10. Four cases presented non-symptomatic intracranial hemorrhage. No symptomatic intracranial hemorrhage and other complications occurred. Conclusions Distal embolization combined with simultaneous carotid stenting is a feasible strategy for acute ischemic stroke due to anterior circulation tandem occlusion.

Key words: Stroke, Brain ischemia, Arterial occlusive diseases, Carotid artery, internal, Stents

摘要：

目的探讨远端机械取栓结合同期颈动脉支架植入术治疗前循环颅内大血管及颈内动脉颅外段串联闭塞导致的急性缺血性卒中的有效性和安全性。方法选择2019年1-12月确诊的前循环颅内动脉闭塞合并同侧颈内动脉起始部重度狭窄或闭塞患者10例，采用球囊扩张颈内动脉起始部病变，通过导引导管后先行远端机械取栓再行颈动脉支架植入术。分别采用改良脑梗死溶栓血流分级（mTICI）、美国国立卫生研究院卒中量表（NIHSS）、改良Rankin量表（mRS）评价术后即刻闭塞血管再通情况、术后24 h神经功能缺损程度及术后90 d预后，记录术后症状性或非症状性颅内出血及手术并发症情况。结果 10例患者均顺利完成颅外血管支架植入术及远端支架取栓术，术后即刻mTICI 2b级5例、3级3例、2a级1例、0级1例，血管再通率8/10例；其中1例术后7 d颈内动脉颅外段再闭塞但临床症状无恶化。术后24 h症状明显改善6例，NIHSS评分均较基线下降≥ 4分。术后90 d mRS评分0分2例、1分1例、2分1例、3分4例、4分1例、6分1例（死亡），预后良好率4/10例。术后有4例发生非症状性颅内出血。结论远端机械取栓结合同期颈动脉支架植入术是一种治疗前循环颅内大血管及同侧颈内动脉颅外段串联闭塞致急性缺血性卒中的可行方法。

关键词: 卒中, 脑缺血, 动脉闭塞性疾病, 颈内动脉, 支架

LING Ye-ping, ZHANG Guang, XU Shan-cai, SHI Huai-zhang. Endovascular treatment for acute ischemic stroke due to the anterior circulation tandem occlusion[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2020, 20(11): 993-999.

凌冶平, 张广, 徐善才, 史怀璋. 前循环串联闭塞致急性缺血性卒中血管内治疗[J]. 中国现代神经疾病杂志, 2020, 20(11): 993-999.

/ / Recommend / Download Citations

URL: https://journal11.magtechjournal.com/cjcnn/EN/10.3969/j.issn.1672-6731.2020.11.011

https://journal11.magtechjournal.com/cjcnn/EN/Y2020/V20/I11/993

References

[1] Gory B, Haussen DC, Piotin M, Steglich-Arnholm H, Holtmannsp-tter M, Labreuche J, Kyheng M, Taschner C, Eiden S, Nogueira RG, Papanagiotou P, Boutchakova M, Siddiqui AH, Lapergue B, Dorn F, Cognard C, Killer M, Mangiafico S, Ribo M, Psychogios MN, Spiotta AM, Labeyrie MA, Biondi A, Mazighi M, Turjman F; 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[J]. Eur J Neurol, 2018, 25:1115-1120.
[2] Jadhav AP, Zaidat OO, Liebeskind DS, Yavagal DR, Haussen DC, Hellinger FR Jr, Jahan R, Jumaa MA, Szeder V, Nogueira RG, Jovin TG. Emergent management of tandem lesions in acute ischemic stroke[J]. Stroke, 2019, 50:428-433.
[3] Rangel-Castilla L, Rajah GB, Shakir HJ, Shallwani H, Gandhi S, Davies JM, Snyder KV, Levy EI, Siddiqui AH. Management of acute ischemic stroke due to tandem occlusion:should endovascular recanalization of the extracranial or intracranial occlusive lesion be done first[J]? Neurosurg Focus, 2017, 42:E16.
[4] Chinese Society of Neurology, Chinese Stroke Society. Chinese guidelines for diagnosis and treatment of acute ischemic stroke 2018[J]. Zhonghua Shen Jing Ke Za Zhi, 2018, 51:666-682.[中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2018[J]. 中华神经科杂志, 2018, 51:666-682.]
[5] Zhang G, Ji ZY, Shi HZ, Xu SC, Qi JT, Zhu SY, Zhou PQ. A single-center study on endovascular thrombectomy for acute ischemic stroke[J]. Zhongguo Xian Dai Shen Jing Ji Bing Za Zhi, 2017, 17:800-805.[张广, 季智勇, 史怀璋, 徐善才, 亓敬涛, 朱仕逸, 周配权. 急性缺血性卒中血管内机械取栓单中心临床研究[J]. 中国现代神经疾病杂志, 2017, 17:800-805.]
[6] Wahlgren N, Ahmed N, Dávalos A, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kuelkens S, Larrue V, Lees KR, Roine RO, Soinne L, Toni D, Vanhooren G; SITS-MOST investigators. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST):an observational study[J]. Lancet, 2007, 369:275-282.
[7] von Kummer R, Broderick JP, Campbell BC, Demchuk A, Goyal M, Hill MD, Treurniet KM, Majoie CB, Marquering HA, Mazya MV, San Román L, Saver JL, Strbian D, Whiteley W, Hacke W. The Heidelberg bleeding classification:classification of bleeding events after ischemic stroke and reperfusion therapy[J]. Stroke, 2015, 46:2981-2986.
[8] Hacke W, Kaste M, Fieschi C, Von Kummer R, Davalos A, Meier D, Larrue V, Bluhmki E, Davis S, Donnan G, Schneider D, Diez-Tejedor E, Trouillas P; Second European-Australasian Acute Stroke Study Investigators. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS Ⅱ)[J]. Lancet, 1998, 352:1245-1251.
[9] Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, Von Kummer R, Wahlgren N, Toni D; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke[J]. N Engl J Med, 2008, 359:1317-1329.
[10] Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV. Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion[J]. Stroke, 2005, 36:869-871.
[11] Wilson MP, Murad MH, Krings T, Pereira VM, O'kelly C, Rempel J, Hilditch CA, Brinjikji W. Management of tandem occlusions in acute ischemic stroke-intracranial versus extracranial first and extracranial stenting versus angioplasty alone:a systematic review and meta-analysis[J]. J Neurointerv Surg, 2018, 10:721-728.
[12] Marnat G, Bühlmann M, Eker OF, Gralla J, Machi P, Fischer U, Riquelme C, Arnold M, Bonafé A, Jung S, Costalat V, Mordasini P. Multicentric experience in distal-to-proximal revascularization of tandem occlusion stroke related to internal carotid artery dissection[J]. AJNR Am J Neuroradiol, 2018, 39:1093-1099.
[13] Behme D, Molina CA, Selim MH, Ribo M. Emergent carotid stenting after thrombectomy in patients with tandem lesions[J]. Stroke, 2017, 48:1126-1128.
[14] Gory B, Piotin M, Haussen DC, Steglich-Arnholm H, Holtmannsp-tter M, Labreuche J, Taschner C, Eiden S, Nogueira RG, Papanagiotou P, Boutchakova M, Siddiqui A, Lapergue B, Dorn F, Cognard C, Killer-Oberpfalzer M, Mangiafico S, Ribo M, Behme D, Spiotta AM, Mazighi M, Turjman F. Thrombectomy in acute stroke with tandem occlusions from dissection versus atherosclerotic cause[J]. Stroke, 2017, 48:3145-3148.
[15] Papanagiotou P, Haussen DC, Turjman F, Labreuche J, Piotin M, Kastrup A, Steglich-Arnholm H, Holtmannsp-tter M, Taschner C, Eiden S, Nogueira RG, Boutchakova M, Siddiqui A, Lapergue B, Dorn F, Cognard C, Killer M, Mangiafico S, Ribo M, Psychogios MN, Spiotta A, Labeyrie MA, Biondi A, Mazighi M, Richard S, Anxionnat R, Bracard S, Gory B; TITAN Investigators. Carotid stenting with antithrombotic agents and intracranial thrombectomy leads to the highest recanalization rate in patients with acute stroke with tandem lesions[J]. JACC Cardiovasc Interv, 2018, 11:1290-1299.
[16] Papanagiotou P, Roth C, Walter S, Behnke S, Grunwald IQ, Viera J, Politi M, Körner H, Kostopoulos P, Haass A, Fassbender K, Reith W. Carotid artery stenting in acute stroke[J]. J Am Coll Cardiol, 2011, 58:2363-2369.
[17] Steglich-Arnholm H, Holtmannspötter M, Kondziella D, Wagner A, Stavngaard T, Cronqvist ME, Hansen K, Højgaard J, Taudorf S, Krieger DW. Thrombectomy assisted by carotid stenting in acute ischemic stroke management:benefits and harms[J]. J Neurol, 2015, 262:2668-2675.
[18] Heck DV, Brown MD. Carotid stenting and intracranial thrombectomy for treatment of acute stroke due to tandem occlusions with aggressive antiplatelet therapy may be associated with a high incidence of intracranial hemorrhage[J]. J Neurointerv Surg, 2015, 7:170-175.
[19] Lockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, Dorn F. Mechanical thrombectomy in tandem occlusion:procedural considerations and clinical results[J]. Neuroradiology, 2015, 57:589-598.
[20] Akp?nar S, Gelener P. Endovascular treatment of acute tandem occlusion strokes and stenting first experience[J]. J Clin Neurosci, 2018, 47:328-331.

Please choose a citation manager

Content to export