Thrombectomy in Acute Stroke With Tandem Occlusions From Dissection Versus Atherosclerotic Cause
Background and Purpose—Tandem steno-occlusive lesions were poorly represented in randomized trials and represent a major challenge for endovascular thrombectomy in acute anterior circulation strokes. The impact of the cervical carotid lesion cause (ie, atherosclerotic versus dissection) on outcome of tandem patients endovascularly treated remains to be assessed.
Methods—We retrospectively analyzed individual data of prospectively collected consecutive tandem patients treated with endovascular thrombectomy. The primary outcome was favorable outcome at 90 days (modified Rankin Scale score of 0–2). Secondary efficacy outcomes included successful reperfusion (modified Thrombolysis in Cerebrovascular Infarction scores of 2b-3), time to reperfusion, and safety outcomes encompassed procedural complications, symptomatic intracerebral hemorrhage, and 90-day mortality.
Results—Among the 295 included patients, 65 had cervical carotid dissection and 230 had cervical carotid atherosclerotic cause. The rate of favorable outcome was 56.3% in the dissection group versus 47.6% in the atherosclerotic arm (center-, age-, and admission National Institutes of Health Stroke Scale–adjusted odds ratio, 1.08; 95% confidence interval, 0.50–2.30; P=0.85). No significant differences were observed in secondary outcomes. The rates of successful reperfusion, symptomatic intracerebral hemorrhage, and 90-day mortality were 78.5% versus 74.5% (P=0.13), 4.6% versus 5.2% (P=1.0), and 7.8% versus 15.3% (P=0.94) in the dissection versus atherosclerotic groups, respectively. The median procedural time was 76 minutes (interquartile range, 52–95 minutes) in the dissection group and 67 minutes (interquartile range, 45–98 minutes) in the atherosclerotic group (P=0.24).
Conclusions—We found no differences in the outcomes of patients with anterior circulation tandem atherosclerotic and dissection lesions treated with endovascular thrombectomy. Further studies are warranted.
Endovascular thrombectomy (ET) of acute stroke related to anterior circulation tandem lesions is technically challenging but may lead to similar outcomes as compared with patients with isolated intracranial occlusions.1 The potential impact of the 2 most common carotid steno-occlusive causes (atherosclerotic and dissection) on reperfusion and clinical outcomes after ET is not clear. We aim to compare outcomes of patients with tandem lesions from atherosclerosis and dissection treated with ET in a large individual patient data pooled analysis.
TITAN (Thrombectomy in Tandem Lesions) collaboration pooled individual data of prospectively collected thrombectomy databases across 18 institutions for all consecutive anterior circulation tandem patients who underwent emergent ET. A tandem lesion was defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery (ICA) lesion (complete occlusion or severe stenosis ≥90% NASCET; Figure 1). The cause of the cervical ICA lesion was defined according to its morphology on angiograms (suprabulbar flame-shaped lesion for dissection and calcified bulbar lesion for atherosclerosis). Patients with unclear cause or >1 cause were excluded. Management of tandem lesions was detailed in the online-only Data Supplement. The institutional review boards approved the study.
The primary outcome measure was the favorable outcome defined as 90-day modified Rankin Scale scores of 0 to 2. Secondary outcomes included successful reperfusion (modified Thrombolysis in Cerebrovascular Infarction scores of 2b-3), complete reperfusion (modified Thrombolysis in Cerebrovascular Infarction score of 3), all-cause 90-day mortality, any procedural-related complications, and symptomatic intracerebral hemorrhage according to the ECASS-2 criteria (European Cooperative Acute Stroke Study).2
Continuous variables are expressed as mean±SD or median (interquartile range), and categorical variables are expressed as numbers (percentage). Bivariate comparisons in baseline characteristics and outcomes between the 2 study groups (cervical ICA dissection versus cervical ICA atherosclerosis) were made using χ2 test (or Fisher exact test when the expected cell frequency was <5) for categorical variables, Student’s t test for Gaussian continuous variables, and Mann–Whitney U test for non-Gaussian continuous and ordinal categorical variables, as appropriate (see the online-only Data Supplement for further details).
Of 454 screened patients with tandem lesions, 127 were excluded because of the absence of data on the cause of cervical ICA lesions (Figure I in the online-only Data Supplement). Sixty-five patients had a cervical ICA dissection, and the remaining 230 a cervical ICA atherosclerotic lesion. Patients with dissection were younger than patients with cervical ICA atherosclerosis type (mean age, 52 versus 67 years; P<0.0001) (Table I in the online-only Data Supplement). Although hypertension and hypercholesterolemia were less frequent in the dissection group, the rates of antiplatelet and heparin therapy used during procedure were similar. The cervical ICA procedure differed between the 2 groups (P=0.009) with a higher rate of cervical ICA angioplasty alone in the atherosclerosis group (19.2% versus 5.9%).
Figure 2 shows the 90-day clinical outcome according to the study group. As shown in the Table, there was no difference in favorable outcome rate between the study groups, with an odds ratio for dissection of 1.08 (95% confidence interval, 0.50–2.30) after prespecified adjustment on center, age, and admission National Institutes of Health Stroke Scale. Similar result was found after additional adjustment on the group baseline differences (hypertension, thrombolysis, intracranial ICA complete occlusion, and cervical procedure), with a fully adjusted odds ratio of 1.01 (95% confidence interval, 0.45–2.24). About secondary outcomes, we found also no difference between the 2 groups, except a nonsignificant difference toward a higher successful reperfusion in dissection group with a fully adjusted odds ratio of 2.19 (95% confidence interval, 0.91–5.25; P=0.080). Among patients with successful reperfusion, the time to achieved successful reperfusion from groin puncture did not differ between groups (median [interquartile range], 76 minutes [52–95 minutes] versus 67 minutes [45–98 minutes]; P=0.24).
Our study demonstrated that patients with atherosclerotic and dissection causes of anterior circulation tandem large-vessel occlusion strokes presented similar outcomes after ET.
We found no differences in the clinical outcomes of tandem patients, whereas patients with dissection were significantly younger and exhibited a lower prevalence of vascular risk factors. Arterial dissection is an acute process, hampering the opportunity to develop cerebral circulation collaterals (such as cardioembolic strokes), which is a well-known predictive factor of good outcome after reperfusion.3 The situation for the atherosclerotic process is different, as the latter evolves slowly, enhancing the possibility to collateral development. Atheroembolic strokes from stenoocclusive cervical ICA lesions have been associated with better leptomeningeal collateral flow compared with cardioembolic strokes.4
Our study showed similar rates of successful reperfusion in both atherosclerotic and dissection groups. A similar successful reperfusion rate was reported in a recent meta-analysis.5 Interestingly, time to endovascular reperfusion was also similar between the 2 groups.
No differences were observed in the safety outcomes. Emergent stenting raises the concern of stent thrombosis while increasing hemorrhagic risk by abruptly increasing perfusion pressures, especially with the use of the antiplatelet therapy or in the setting of thrombolysis. A more conservative approach may be considered for dissection in case good collaterals is observed,6 especially considering the potential of healing of the dissected ICA over time. In our study, stenting of the cervical lesion was the therapeutic approach chosen for the majority of the patients without significant differences in the outcomes based on the stroke cause, and the rates of antiplatelet and heparin therapy used during ET were similar.
Our study had several limitations including retrospective, noncontrolled study design, and lack of a core laboratory. In addition, all participating centers had individual selection protocols (which may have introduced selection bias) and heterogeneous antithrombotic strategies. Conversely, strengths of our study included the multicenter design, the use of contemporary technology, and the fact that this is the largest described series of patients who underwent ET for large-vessel occlusion strokes from tandem lesions.
Tandem stroke patients consecutive to atherosclerosis and dissection treated with ET had similar 90-day clinical outcomes. Thus, the cervical ICA lesion cause may not influence the therapeutic decision of the treating physicians.
Sources of Funding
This study was supported by Stryker.
Dr Holtmannspötter has received honoria for consultancy and proctoring for Medtronic, Stryker, and Microvention. Dr Nogueira has received honoria from Stryker Neurovascular for TREVO 2 trial (Thrombectomy Revascularisation of Large Vessel Occlusions in Acute Ischemic Stroke) and DAWN Trial (Trevo and Medical Management Versus Medical Management Alone in Wake Up and Late Presenting Strokes), from Medtronic for SWIFT (Solitaire FR With the Intention for Thrombectomy) and SWIFT PRIME Trials (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke) Steering Committee, and STAR Trial core laboratory (significant), from Penumbra for 3D Separator Trial Executive Committee, and from Neuravi for ARISE-2 (Analysis of Revascularization in Ischemic Stroke With EmboTrap) Steering Committee; Dr Siddiqui reports grants from National Institutes of Health/NINDS/NIBIB, University at Buffalo, personal fees from Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, and Lazarus Effect, non-financial support from Codman & Shurtleff, Inc, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra, Stryker, Pulsar Vascular, MicroVention, Lazarus Effect, Blockade Medical, other from null, outside the submitted work; Dr Spiotta has stock from Penumbra and received honoria for consultancy and proctoring for Penumbra, and Stryker; Dr Turjman has received honoria for consultancy and proctoring for Medtronic, Stryker Codman, and Balt. The other authors report no conflicts.
Guest Editor for this article was Tatjana Rundek, MD, PhD.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.117.018264/-/DC1.
- Received June 1, 2017.
- Revision received July 25, 2017.
- Accepted August 21, 2017.
- © 2017 American Heart Association, Inc.
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