Treatment Approaches and Outcomes for Acute Anterior Circulation Stroke Patients with Tandem Lesions

J Stroke Cerebrovasc Dis. 2021 Feb;30(2):105478. doi: 10.1016/j.jstrokecerebrovasdis.2020.105478. Epub 2020 Nov 26.

Abstract

Objectives: Endovascular thrombectomy (EVT) has revolutionized stroke care for large vessel occlusions (LVOs). However, over half treated remain functionally disabled or die. Patients with tandem lesions, or severe stenosis/occlusion of the cervical internal carotid artery (ICA) with intracranial LVO, may have technical EVT challenges and worse outcomes. We sought to compare treatments and outcomes for patients with anterior circulation tandem lesions versus isolated LVOs.

Materials and methods: Consecutive tandem lesion and isolated intracranial LVO patients were identified at a single center. Demographics, medical history, presentations, treatments, and outcomes were collected and analyzed.

Results: From 381 EVT patients, 62 had tandem lesions related to atherosclerosis (74%) or dissection (26%). Compared to isolated intracranial LVOs, they were younger (63 vs 70, p = 0.003), had less atrial fibrillation (13% vs 40%, p < 0.0001), less adequate reperfusion (TICI 2b-3, 58% vs 82%, p < 0.0001), more intracranial hemorrhage (ICH, 13% vs 5%, p = 0.037), but similar 90-day functional independence (mRS 0-2, 34% vs 43%, p = 0.181). The cervical ICA was treated before intracranial EVT (57%), after (13%), not acutely (22%), or was inaccessible (8%). Acute cervical ICA treatments were stenting (57%) or angioplasty alone (13%). Neither acute stenting nor order of treatment was associated with outcomes (TICI 2b-3, ICH, or 90-day mRS 0-2). Among acutely stented, neither alteplase nor antiplatelets were associated with outcomes or stent patency.

Conclusions: Tandem lesions were associated with less reperfusion, more ICH, but similar 90-day functional independence. No treatment approach was associated with outcomes. These data illustrate the technical challenges of tandem lesion treatment and underscore the importance of developing new approaches.

Keywords: Acute ischemic stroke; Carotid stenosis; Carotid stenting; Endovascular thrombectomy; Large vessel occlusion; Tandem lesions.

Publication types

  • Comparative Study
  • Observational Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Carotid Artery, Internal, Dissection / diagnostic imaging
  • Carotid Artery, Internal, Dissection / mortality
  • Carotid Artery, Internal, Dissection / physiopathology
  • Carotid Artery, Internal, Dissection / therapy*
  • Carotid Stenosis / diagnostic imaging
  • Carotid Stenosis / mortality
  • Carotid Stenosis / physiopathology
  • Carotid Stenosis / therapy*
  • Cerebrovascular Circulation
  • Databases, Factual
  • Endovascular Procedures* / adverse effects
  • Endovascular Procedures* / instrumentation
  • Endovascular Procedures* / mortality
  • Female
  • Functional Status
  • Humans
  • Intracranial Arteriosclerosis / diagnostic imaging
  • Intracranial Arteriosclerosis / mortality
  • Intracranial Arteriosclerosis / physiopathology
  • Intracranial Arteriosclerosis / therapy*
  • Ischemic Stroke / diagnostic imaging
  • Ischemic Stroke / mortality
  • Ischemic Stroke / physiopathology
  • Ischemic Stroke / therapy*
  • Male
  • Middle Aged
  • Recovery of Function
  • Retrospective Studies
  • Risk Factors
  • Stents
  • Thrombectomy* / adverse effects
  • Thrombectomy* / mortality
  • Thrombolytic Therapy* / adverse effects
  • Thrombolytic Therapy* / mortality
  • Time Factors
  • Treatment Outcome