Tandem Occlusions
2021; Lippincott Williams & Wilkins; Volume: 52; Issue: 10 Linguagem: Inglês
10.1161/strokeaha.121.036219
ISSN1524-4628
AutoresLuciana Catanese, Ashkan Shoamanesh, Alexandre Y. Poppe,
Tópico(s)Stroke Rehabilitation and Recovery
ResumoHomeStrokeVol. 52, No. 10Tandem Occlusions Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBTandem OcclusionsA Tale of Two Treatments Luciana Catanese, MD, Ashkan Shoamanesh, MD, FRCPC and Alexandre Y. Poppe, MD, CM, FRCPC Luciana CataneseLuciana Catanese Correspondence to: Luciana Catanese, MD, Assistant Professor of Medicine (Neurology), Director, Stroke Fellowship Program, McMaster University, 237 Barton St E, HGH-DBCVSRI C4-122, Hamilton, Ontario, L8L 2X2, Canada. Email E-mail Address: [email protected] https://orcid.org/0000-0002-8696-5211 Department of Medicine (Neurology), McMaster University (L.C.). , Ashkan ShoamaneshAshkan Shoamanesh Department of Medicine (Neurology), McMaster University/Population Health Research Institute (A.S.). and Alexandre Y. PoppeAlexandre Y. Poppe Department of Neurosciences, Centre Hospitalier de l'Université de Montréal (A.Y.P.). Originally published10 Aug 2021https://doi.org/10.1161/STROKEAHA.121.036219Stroke. 2021;52:3106–3108This article is a commentary on the followingEndovascular Therapy of Anterior Circulation Tandem OcclusionsOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 10, 2021: Ahead of Print See related article, p 3097The landmark endovascular thrombectomy (EVT) trials have revolutionized the acute care of anterior circulation strokes resulting from large vessel occlusion.1 However, the nonstandardized nature of the procedures conducted in these trials has left several unanswered questions regarding the best management of select subpopulations, such as patients with tandem occlusions (TO). TO are characterized by the coexistence of a cervical carotid artery (c-ICA) occlusion or high-grade stenosis and an ipsilateral intracranial large vessel occlusion (ICA or M1/M2).2 These types of occlusions are present in up to a third of all patients with stroke undergoing EVT and are associated with worse clinical outcomes. Two treatments strategies have been used in clinical trials at the discretion of the operators: acute c-ICA stenting plus antithrombotic therapy or intracranial thrombectomy alone.3 Extracranial ICA angioplasty is often implemented alongside these treatment modalities. While acute c-ICA stenting appears feasible,4 it has been associated with higher rates of ICH, and a risk of in-stent thrombosis, iatrogenic artery-artery embolization, and hemodynamic instability during stent deployment.3,5 Conversely, a no-stent approach could allow for higher risk of stroke recurrence and infarct progression as a result of decreased cerebral perfusion.3 As randomized controlled trials (RCTs) evaluating the best acute management of the extracranial lesion are still ongoing (URL: https://www.clinicaltrials.gov; Unique identifier: NCT03978988 and NCT04261478), the optimal management of the c-ICA at the time of EVT remains uncertain.In this issue of Stroke, Anadani et al6 describe an individual patient data pooled analysis of 603 TO individuals from the Endovascular Treatment in Ischemic Stroke7 and the international Thrombectomy In Tandem Lesions (TITAN) registries.8 TITAN and Endovascular Treatment in Ischemic Stroke are observational multicenter registries of anterior circulation large vessel strokes treated with EVT, with TITAN including solely TO patients. The treatment of the c-ICA lesions in these cohorts was left at the discretion of the operators and included acute stenting (stent group) versus thrombectomy alone (no-stent group), with and without angioplasty. Acute c-ICA stenting was performed in 56% of patients and propensity score matching was used to adjust for confounding. The authors showed that patients in the stent group achieved more successful reperfusion (adjusted odds ratio, 1.19) had better functional outcomes at 90 days (12% absolute difference) and higher rates of any ICH (adjusted odds ratio, 1.10), while symptomatic ICH and parenchymal hematoma type 2 were not significantly different. A subgroup analysis suggested heterogeneity in the treatment effect according to the National Institutes of Health Stroke Scale and carotid lesion type, with benefit confined to patients with TO of atherosclerotic origin and in patients presenting with National Institutes of Health Stroke Scale score <10. The result of this pooled analysis is concordant with a more recent meta-analysis9 which found that patients with TO undergoing periprocedural c-ICA stenting during EVT have a better prognosis than those receiving a more conservative approach, without significant safety concerns. Although in the current study, there was an increased risk of all ICH likely driven by the concomitant use of antithrombotic agents, often given in addition to intravenous thrombolysis, or perhaps greater reperfusion injury, it did not impact functional outcomes. In addition, the procedural complications and treatment times were similar in each group.The current study adds to the literature by providing data from a large, well-characterized cohort, but also by attempting to minimize confounding using propensity score methods, which has not been done before to address this question in patients with TO. Although many recent publications by the TITAN group and others, including a recent large German registry,10 have supported the emerging notion that acute c-ICA stenting confers benefit to patients with TO, the potential for confounding by indication limits the interpretation of these findings and, as demonstrated by the current report, about 40% of patients with TO do not undergo stenting in clinical practice. This variation in treatment approach reflects the community equipoise that exists and sets the appropriate stage for RCTs like TITAN (NCT03978988) and EASI-TOC (Endovascular Acute Stroke Intervention - Tandem Occlusion Trial; NCT04261478) to address an important lingering management question in EVT.Relatively, novel findings in the current report that may inform current practice, while awaiting validation in RCTs, include the apparent absence of benefit of stenting in three subgroups of patients: those with carotid dissection, an National Institutes of Health Stroke Scale score of ≥10 or an Alberta Stroke Program Early CT Score <8. The arguably more favorable natural history of carotid occlusion due to dissection versus atherosclerosis suggests that routine c-ICA stenting in this population may not be warranted and explains why these patients are excluded from the EASI-TOC trial. The lack of benefit of stenting in patients with more severe strokes and worse Alberta Stroke Program Early CT Scores might be mediated by a higher risk of symptomatic ICH among patients with large infarct cores. Alternatively, if the benefit of acute stenting is driven in part by a reduction in stroke recurrence, then patients with more severe index strokes may already have a disabled outcome, and stroke recurrence (or lack thereof) may not alter their level of 90-day disability in a way that is adequately captured by dichotomized modified Rankin Scale scores.In this cohort, the rate of successful intracranial recanalization was almost 20% higher among patients with c-ICA stenting, a finding that other recent large10 and prospective11 studies have also reported. While data is not available regarding the order of stenting relative to intracranial recanalization (before or after), it stands to reason that when done after intracranial thrombectomy, stenting is more often undertaken only if reperfusion was achieved successfully. This suggests that selection bias might occur in favor of stenting, which would not be adjusted for with propensity matching of baseline characteristics. The causal impact of stenting on intracranial recanalization thus remains to be proven. In this regard, a better understanding of reperfusion would have also benefitted from reporting the intracranial occlusion locations in both groups. Lastly, the trade-off between the risk of stent thrombosis/recurrent stroke and hemorrhagic transformation is influenced by the periprocedural antithrombotic regimen used, details of which are not reported, and have evolved in recent years.12With a timely analysis of 2 well-studied cohorts, Anadani et al6 have added further observational evidence supporting a possible benefit of acute c-ICA stenting in patients with TO undergoing EVT. In the absence of definitive findings from RCT's, it is reasonable to consider acute carotid stenting in patients with TO undergoing EVT. Ongoing RCTs will provide more definite answers in the coming years, and will capture, beyond 90-day outcomes, whether stenting additionally prevents recurrent ipsilateral stroke and improves functional outcomes up to 1 year after the index event.Disclosures Dr Catanese/Dr Shoamanesh are co-investigators of the EASI-TOC study (Endovascular Acute Stroke Intervention - Tandem Occlusion Trial). Dr Poppe received research grant from Stryker for EASI-TOC study, principal investigator of E ASI-TOC study.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Disclosures, see page 3107.Correspondence to: Luciana Catanese, MD, Assistant Professor of Medicine (Neurology), Director, Stroke Fellowship Program, McMaster University, 237 Barton St E, HGH-DBCVSRI C4-122, Hamilton, Ontario, L8L 2X2, Canada. Email luciana.[email protected]caReferences1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, et al.. 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Predictors and clinical impact of delayed stent thrombosis after thrombectomy for acute stroke with tandem lesions.AJNR Am J Neuroradiol. 2019; 40:533–539. doi: 10.3174/ajnr.A5976Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesEndovascular Therapy of Anterior Circulation Tandem OcclusionsMohammad Anadani, et al. Stroke. 2021;52:3097-3105 October 2021Vol 52, Issue 10Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.121.036219PMID: 34372673 Originally publishedAugust 10, 2021 KeywordshemodynamicsEditorialsthrombectomystentsangioplastythrombosisPDF download Advertisement SubjectsCerebrovascular ProceduresIschemic Stroke
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