Two in One: Endovascular Treatment of Acute Tandem Occlusions in the Anterior Circulation

Clin Neuroradiol. 2015 Dec;25(4):397-402. doi: 10.1007/s00062-014-0318-2. Epub 2014 Jul 3.


Purpose: Acute major stroke with high-grade stenosis or occlusion of the extracranial internal carotid artery (ICA) and additional intracranial large artery occlusion is increasingly treated with a mechanical endovascular approach by extracranial stenting and intracranial thrombectomy due to poor response to systemic thrombolysis with recombinant tissue plasminogen activator (rtPA). This article presents a single centre cohort of this challenging subtype of stroke, describing the technical procedure and analysing the angiographic and clinical outcome.

Methods: Clinical and imaging data of all consecutive patients between July 2008 and March 2013 with intracranial artery occlusion in the anterior circulation and additional occlusion or pseudo-occlusion of the cervical ICA were retrospectively analysed with respect to demographical and clinical characteristics. Technical approach, recanalization rate, recanalization time and short-term clinical outcome were determined.

Results: A total of 43 patients with tandem occlusion in the anterior circulation met the inclusion criteria. Out of these, 32 (74.4%) occlusions and 11 (25.6%) pseudo-occlusions of the extracranial ICA with additional occlusion of the distal segment of the ICA in 7.0% (3/43), the M1-segment of the middle cerebral artery (MCA) in 81.4% (35/43) or the M2-segment of the MCA in 11.6% (5/43) of cases were treated with combined endovascular approach including extracranial stenting with angioplasty and intracranial mechanical thrombectomy. In 76.7% of cases, an angiographic recanalization result of 2b or 3 using the Thrombolysis in Cerebral Infarction (TICI) score was achieved. Mean time from first angiographic series to recanalization was 103 min. A modified Rankin Scale (mRS) score of ≤ 2 was achieved in 32.6% at the time of discharge.

Conclusion: 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 result and clinical outcome.

Keywords: Stent; Stroke; Tandem occlusion; Thrombectomy.

Publication types

  • Clinical Trial

MeSH terms

  • Aged
  • Brain Infarction / diagnostic imaging*
  • Brain Infarction / surgery*
  • Carotid Stenosis / diagnostic imaging*
  • Carotid Stenosis / surgery*
  • Cerebral Angiography / methods
  • Cerebral Revascularization / instrumentation
  • Cerebral Revascularization / methods
  • Combined Modality Therapy / instrumentation
  • Combined Modality Therapy / methods
  • Endovascular Procedures / methods
  • Female
  • Humans
  • Male
  • Mechanical Thrombolysis / instrumentation
  • Mechanical Thrombolysis / methods*
  • Stents*
  • Surgery, Computer-Assisted / methods
  • Treatment Outcome