John Moshe Gomori MD, Presenter: Consultant, Medymatch Technology Ltd

Ronen Leker MD, Abstract Co-Author: Consultant, MedyMatch Technology Ltd

Roni Peter Eichel MD, Abstract Co-Author: Nothing to Disclose

Jose Enrique Cohen MD, Abstract Co-Author: Nothing to Disclose

Acute tandem occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (IV-tPA) and present an endovascular challenge. We describe our experience with emergent stent-assisted ICA angioplasty and intracranial stent-based thrombectomy of tandem occlusions.

Procedures were performed from 3/2010–12/2013. National Institutes of Health Stroke Score (NIHSS) and Alberta Stroke Program Early CT Score (ASPECTS), occlusion sites, collateral supply, procedural details, and outcomes were retrospectively reviewed with IRB waiver of informed consent.

24 patients, mean age 66 years, mean admission NIHSS score 20.4, and mean ASPECTS 9 were included. Occlusion sites were proximal ICA–MCA trunk in 17 patients, proximal ICA–ICA terminus in six, ICA–MCA–anterior cerebral artery (ACA) in one. Stent-assisted cervical ICA recanalization was achieved in all patients, with unprotected pre-angioplasty in 24/24, unprotected stenting in 16/24 (67%), and protected stenting in 8/24 (33%), followed by stent-thrombectomy in 25 intracranial occlusions. There was complete recanalization/complete perfusion in 19/24 (79%), complete recanalization/partial perfusion in 2/14 (13%), and partial recanalization/partial perfusion in 2/24 (8%) with no procedural morbidity/mortality. Mean time to therapy was 3.8 hours (range 2–5.5). Mean time to recanalization was 51 minutes (range 38–69). At 3-month follow-up, among 17/22 surviving patients (77%), 13/17 (76%) presented mRS 0–2 and 3/17(18%) were mRS 3.

In acute tandem ICA–MCA/distal ICA occlusions, extracranial stenting followed by intracranial stent-based thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.

With newer techniques, acute tandem carotid - intracranial occlusive disease is now amenable to  treatment with high success and low complication rates

Gomori, J, Leker, R, Eichel, R, Cohen, J, Extracranial Carotid Artery Stenting Followed by Intracranial Stent-based Thrombectomy for Acute Tandem Occlusive Disease.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14008778.html