Acute ischemic stroke due to tandem occlusions: a single center experience

Background: Acute ischemic stroke caused by tandem occlusions present treatment challenges. Only a relatively small number of patients fully recanalize following intra-venous fibrinolysis. Both proximal-to-distal and distal-to-proximal approaches have been reported without a clear consensus over which lesion should be treated first.

Objective: Assess the efficacy and safety of tandem occlusion treatment using the different approaches.

Methods: Single-center retrospective review of a prospectively maintained database of consecutive ischemic stroke patients from 2014 to 2017. The inclusion criteria consisted of patients undergoing endovascular treatment for tandem occlusions. An exploratory analysis was performed comparing interventional approaches. There were essentially two types of approach, proximal-to-distal (cervical carotid artery stenting and/or angioplasty followed by intracranial thrombectomy) and distal-to-proximal (intracranial thrombectomy followed by cervical carotid artery stenting and/or angioplasty).

Results: A total of 23 patients were identified, nine of whom received IV tPA before undergoing endovascular treatment. Sixteen patients underwent a proximal-to-distal approach with approach with first carotid artery stenting in 12 patients, angioplasty in 2, and thrombectomy in 2, followed by intracranial thrombectomy, whereas 7 patients underwent distal-to-proximal approach with intracranial thrombectomy performed first. For intracranial thrombectomy procedures, thrombectomy with stent-retrieval alone was used in 1 patient, aspiration alone was used in 1, and a combination of aspiration and stent-retriever thrombectomy was used in the remaining 21 patients. The average time to revascularization was 36 minutes (n = 16). Successful recanalization (TICI 2B or 3) was achieved in 22 (96%) patients. At 24-hour follow-up, the incidence of ICH was 1/23 (4%). There was 1 (4%) in-hospital death. In the exploratory analysis, we found no statistical difference between both groups. Favorable outcomes (mRS ≤ 2) were achieved at 3 months in 13 (72%) of 18 patients available for follow-up.

Conclusion: Simultaneous treatment of tandem occlusion is safe and feasible with favorable clinical outcomes at discharge and at 90 days. Further studies are required to determine which interventional approach is superior.