AUTHOR=Bücke Philipp , Aguilar Pérez Marta , AlMatter Muhammad , Hellstern Victoria , Bäzner Hansjörg , Henkes Hans 

TITLE=Functional Outcome and Safety of Intracranial Thrombectomy After Emergent Extracranial Stenting in Acute Ischemic Stroke Due to Tandem Occlusions

JOURNAL=Frontiers in Neurology

VOLUME=9

YEAR=2018

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2018.00940

DOI=10.3389/fneur.2018.00940

ISSN=1664-2295

ABSTRACT=<p><bold>Background and Purpose:</bold> Various endovascular approaches to treat acute ischemic stroke caused by extra- intracranial tandem occlusions (TO) exist: percutaneous transluminal angioplasty with or without emergent extracranial carotid stenting (ECS) due to high-grade stenosis preceded or followed by intracranial mechanical and/or aspiration thrombectomy (MT). Which treatment strategy to use is still a matter of debate.</p><p><bold>Methods:</bold> From our ongoing prospective stroke registry we retrospectively analyzed 1,071 patients with anterior circulation stroke getting endovascular treatment within 6 h of symptom onset. ECS prior to intracranial MT for TO (<italic>n</italic> = 222) was compared to MT as standard of care (control group; acute intracranial vessel occlusion without concomitant ipsilateral ICA-occlusion or high-grade stenosis [C; <italic>n</italic> = 849]). Good functional outcome (mRS ≤ 2 at 3 months), mortality rates, frequencies of symptomatic intracranial hemorrhage (sICH) and successful recanalization (Thrombolysis in Cerebral Infarction Score [TICI] 2b or 3) were assessed. In subgroup analyses we tried to detect possible influences of stroke etiology, dual inhibition of platelet aggregation (IPA; clopidogrel [CLO]: <italic>n</italic> = 83; ticagrelor [TIC]: <italic>n</italic> = 137; in combination with Aspirin) and intravenous thrombolysis (IVT).</p><p><bold>Results:</bold> Functional outcome was superior in TO (mRS 0–2: 44.6%) when compared with controls (36.0%; OR [95% CI]: 3.49 [1.59–7.67]; <italic>p</italic> = 0.002). There was no difference in all-cause mortality at 3 months (TO: 21.6%; C: 27.7%; 0.78 [0.47–1.29]; <italic>p</italic> = 0.324), in-hospital mortality (0.76 [0.45–1.30]; <italic>p</italic> = 0.324), sICH (TO: 3.2%; C: 5.0%; 0.70 [0.30–1.59]; <italic>p</italic> = 0.389), and TICI 2b/3 (TO: 89.1%; C: 88.3%; <italic>p</italic> = 0.813). In subgroup-analysis, TIC and CLO did not differ in functional outcome (TIC: 45.3%; CLO: 44.6%; 1.04 [0.51–2.09]; <italic>p</italic> = 0.920) and mortality rates (all-cause mortality: TIC: 23.4%; CLO: 16.9%; 0.75 [0.27–2.13]; <italic>p</italic> = 0.594). sICH was more frequent in TIC (<italic>n</italic> = 7 [5.1%]) vs. CLO (<italic>n</italic> = 0; <italic>p</italic> = 0.048).</p><p><bold>Conclusion:</bold> In our pre-selected cohort, ECS prior to intracranial MT in TO allowed for a good functional outcome that was superior compared to a control population. Mortality rates did not differ. Despite a dual IPA in TO, there was no increase in sICH. CLO and TIC for dual IPA did not differ in terms out outcome and mortality rates. A significant increase in sICH was observed after initial loading with TIC.</p>