Extra- and intracranial tandem occlusions in the anterior circulation - clinical outcome of endovascular treatment in acute major stroke. Poster No.: C-1669 Congress: ECR 2014 Type: Scientific Exhibit Authors: C. J. Maurer, F. Joachimski, J. Mariß, R. Fessl, A. M. Roesler, A. Berlis; Augsburg/DE Keywords: DOI: Neuroradiology brain, Interventional vascular, Emergency, Catheter arteriography, CT-Angiography, Recanalisation, Stents, Ischemia / Infarction 10.1594/ecr2014/C-1669 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 27
Aims and objectives Patients with acute tandem occlusion of the cervical internal carotid artery (ICA) and the terminal carotid segment or the middle cerebral artery (MCA) have a poor clinical outcome when treated with intravenous or intraarterial thrombolysis with tissue plasminogen activator (tpa) (1-4). There is, however, increasing evidence that patients with tandem occlusions may profit from an endovascular mechanical approach with combined extracranial stenting and intracranial thrombectomy (5). We retrospectively analyzed our own patients with major stroke in the anterior circulation presenting with occlusion or high grade stenosis of the extracranial ICA and accompanying intracranial vessel occlusion, who underwent endovascular therapy. Methods and materials All patients in our hospital with large vessel occlusion of the anterior circulation who underwent endovascular therapy between December 2009 and March 2013 were included in this retrospective analysis. In this period, 43 patients received endovascular therapy in our hospital because of symptomatic intracranial occlusion of the middle cerebral artery or the terminal segment of the ICA and preceding occlusion or pseudo-occlusion of the cervical ICA. Pseudoocclusion was considered as high-grade ICA stenosis with residual non-functional flow in the distal ICA. In the same period 166 patients with only a singular occlusion in the anterior circulation were treated via an endovascular approach. All patients received a baseline native cranial CT scan to exclude an intracranial haemorrhage and major infarction in the territory of the MCA (see figure 1). Page 2 of 27
Fig. 1: Dense artery sign in a native CT-scan of a 71 y/o female patient presenting with an initial NIHSS of 13 corresponding to an occlusion of the right middle cerebral artery. References: Neuroradiologie, Klinikum Augsburg - Augsburg/DE Page 3 of 27
Furthermore, a CT angiography (CTA) of the cervical and intracranial arterial vessels was performed documenting the intracranial arterial occlusion and/or the extracranial highgrade stenosis or occlusion of the ICA (see figure 2). Page 4 of 27
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Fig. 2: CT-angiography of the same patient showing an additional occlusion of the right cervical internal carotid artery. References: Neuroradiologie, Klinikum Augsburg - Augsburg/DE In selected patients a CT perfusion imaging was conducted to determine whether a salvageable penumbra exists. Recanalization via an endovascular approach was performed. According to the findings different methods for recanalization were used including intraarterial thrombolysis, mechanical thrombectomy, extra- or intracranial stenting and direct aspiration via an intermediate catheter (see figure 3 to 5). Page 6 of 27
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Fig. 3: Control imaging after placement of a Carotid Wallstent. References: Neuroradiologie, Klinikum Augsburg - Augsburg/DE Page 8 of 27
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Fig. 4: After recanalization of the ICA in the very same patient triaxial approach in elongated vessel anatomy via intermediate catheter in distal ICA and placement of a stent retriever in the occluded middle cerebral artery. References: Neuroradiologie, Klinikum Augsburg - Augsburg/DE Fig. 5: Final control after recanalization of the ICA and MCA. References: Neuroradiologie, Klinikum Augsburg - Augsburg/DE Page 10 of 27
The data of both patient groups - with tandem-occlusion and singular occlusion - were compared as to demographic data, time frame of the recanalizing procedure, methods of recanalization and clinical outcome at time of discharge from the hospital. Images for this section: Page 11 of 27
Fig. 1: Dense artery sign in a native CT-scan of a 71 y/o female patient presenting with an initial NIHSS of 13 corresponding to an occlusion of the right middle cerebral artery. Page 12 of 27
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Fig. 2: CT-angiography of the same patient showing an additional occlusion of the right cervical internal carotid artery. Page 14 of 27
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Fig. 3: Control imaging after placement of a Carotid Wallstent. Page 16 of 27
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Fig. 4: After recanalization of the ICA in the very same patient triaxial approach in elongated vessel anatomy via intermediate catheter in distal ICA and placement of a stent retriever in the occluded middle cerebral artery. Fig. 5: Final control after recanalization of the ICA and MCA. Page 18 of 27
Results In the tandem group we found 11 patients (26%) with an ICA-pseudoocclusion and 32 patients (74%) with a complete occlusion of the cervical ICA. The second occlusion affected the distal segment of the ICA in 3 patients (7%) and the M1-segment of the middle cerebral artery in 40 patients (93%). Of the demographic data statistically significant was only the patients' sex with significantly more male patients in the tandem-group (p-value=0,012). Fig. 6 References: Neuroradiologie, Klinikum Augsburg - Augsburg/DE The significantly higher use of extracranial stents and intermediate catheters in the tandem-group is of course due to the patient selection with extracranial occlusion/ pseudooclusion and the need to pass through the applied stent in the cervical ICA. Page 19 of 27
Fig. 7 References: Neuroradiologie, Klinikum Augsburg - Augsburg/DE Good angiographic outcome was defined as a TICI-score of 2b or 3, which was reached in 77% in the tandem group and in 79% in the group with only a single occlusion. Page 20 of 27
Fig. 8 References: Neuroradiologie, Klinikum Augsburg - Augsburg/DE Page 21 of 27
Fig. 9 References: Neuroradiologie, Klinikum Augsburg - Augsburg/DE Good clinical outcome was defined as a modified Rankin Scale (mrs) of 2 or less. At time of discharge a mrs of # 2 was reached in 34% and in 36% in the group with a single occlusion, the difference not being statistically significant. Images for this section: Page 22 of 27
Fig. 6 Fig. 7 Page 23 of 27
Fig. 8 Page 24 of 27
Fig. 9 Page 25 of 27
Conclusion The limitations of this study are of course the retrospective analysis of the patient data and the inhomogeneous patient selection especially in the patient group with only a single occlusion. Besides, the clinical outcome is available only at time of discharge and not after 90 days. But still, the data show a similar angiographic and clinical outcome in both groups, in patients with a single occlusion and with a tandem occlusion treated with interventional means. And although we still need more trials to compare the effectivness and especially the clinical outcome of an endovascular approach in large vessel occlusions with i.v. thrombolysis alone there is still increasing data that selected patients with major stroke profit from a more aggressive therapy. In summary endovascular therapy of patients with tandem-occlusion in the anterior circulation with emergency extracranial stenting and intracranial mechanical thrombectomy appears to be safe and may lead to a satisfactory angiographic and clinical result, especially compared to low recanalization rates and poor clinical outcome when treated with systemic thrombolysis alone. Personal information Corresponding address: Christoph J Maurer, Department of Neuroradiology, Klinikum Augsburg, Germany christoph.j.maurer@gmail.com References 1. 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; 37:2301-23052. Page 26 of 27
2. Kim YS, Garami Z, Mikulik R et al. Early Recanalization Rates and Clinical Outcomes in Patients with Tandem Internal Carotid Artery/Middle Cerebral Artery Occlusion and Isolated Middle Cerebral Artery Occlusion, Stroke 2005; 36:869-871. 3. Saqqur M, Uchino K, Demchuk AM et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke. 2007 Mar;38(3):948-54. 4. Fischer U, Mono ML, Schroth G et al. Endovascular therapy in 201 patients with acute symptomatic occlusion of the internal carotid artery. Eur J Neurol. 2013 Jul;20(7):1017-24. 5. 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 Sep;23(3):207-15 Page 27 of 27