The results of treatment of patients with tandem occlusions in the acute period of ischemic stroke

Abstract

Objective – to evaluate the efficacy and safety of endovascular treatment in patients with acute ischemic stroke due to tandem occlusions. Materials and methods. The results of the examination and treatment of 237 patients with acute ischemic stroke due to large vessel occlusion who underwent endovascular reperfusion were analyzed. Tandem occlusions (internal carotid ‒ middle cerebral artery) were diagnosed in 65 (27.4 %) cases. Patient age ranged from 29 to 84 years (mean age ‒ 64.8 years). Men predominated among the patients (46 (70.8 %)). Among patients with ischemic stroke due to tandem occlusion, 29 (44.6 %) were diagnosed with atherothrombotic stroke subtype, 27 (41.5 %) had cardioembolic. In 9 (13.9 %) cases the cause of thrombosis was spontaneous dissection of the wall of the internal carotid artery. To assess collateral blood flow, the ACG scale proposed by the American Society for Interventional and Therapeutic Radiology was used. The quality of reperfusion was assessed using the eTICI scale. Analysis of the functional results of patients after 90 days from the onset of the disease was carried out according to the modified Rankine scale (mSR). Results. According to our study, a good angiographic result (eTICI 2b-3) was achieved in 54 (83.1 %) patients. Intraoperative complications were registered in 8 (12.3 %) cases. An analysis of the dependence of the quality of reperfusion on the severity of collateral compensation of a thrombosed artery showed that in patients with developed (ACG 3-4) collaterals (35 (53.8 %)) good reperfusion was achieved in 33 (94.3 %) cases, in patients with mild (ACG 0-2) collateral compensation (30 (46.2 %)) the quality of eTICI 2b-3 reperfusion was achieved only in 21 (70.0 %) cases. It was found that out of 40 (61.5 %) patients with tandem occlusion, in whom arterial puncture was performed within 6 hours after the onset of neurological symptoms, 15 (37.5 %) had 0-2 points for mSR after 90 days. When puncturing the artery later than 6 hours (25 (38.5 %) cases), a good result after 90 days was registered only in 7 (28.0 %) patients. Analysis of the influence of collaterals on the dynamics of changes according to multislice computed tomography revealed that patients with well-defined collaterals (35 (53.8 %) cases) during the control examination had ASPECTS scores from 1 to 9 points (average ‒ 5.3 points). Patients with mild collaterals (30 (46.2 %) observations)) on the ASPECTS scale during the control examination had from 0 to 6 points (average ‒ 2.2 points). During the first day or at the time of discharge, a statistically significant decrease in neurological deficit was observed in the group with successful restoration of cerebral blood flow findings. Conclusions. Many factors influence the clinical efficacy of endovascular reperfusion techniques: hypoperfusion area and area of brain damage according to computed tomography during hospitalization, quality of endovascular reperfusion, time from the onset of the disease, collateral compensation of the thrombosed artery basin, complications during surgery. Well-defined collaterals are a predictor of positive dynamics after successful endovascular reperfusion.

Keywords

• ischemic stroke; tandem occlusion; endovascular treatment; mechanical thrombectomy.