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Revascularization of tandem occlusions in acute ischemic stroke: review of the literature and illustrative case

机译：急性缺血性卒中串联闭塞的血运重建：文献复习和说明性病例

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OBJECTIVE Tandem occlusions continue to represent a major challenge in patients with acute ischemic stroke (AIS). The anterograde approach with proximal to distal revascularization as well as the retrograde approach with distal to proximal revascularization have been reported without clear consensus or standard guidelines. METHODS The authors performed a comprehensive search of the PubMed database for studies including patients with carotid occlusions and tandem distal occlusions treated with endovascular therapy. They reviewed the type of approach employed for endovascular intervention and clinical outcomes reported with emphasis on the revascularization technique. They also present an illustrative case of AIS and concurrent proximal cervical carotid occlusion and distal middle cerebral artery occlusion from their own experience in order to outline the management dilemma for similar cases. RESULTS A total of 22 studies were identified, with a total of 790 patients with tandem occlusions in AIS. Eleven studies used the anterograde approach, 3 studies used the retrograde approach, 4 studies used both, and in 4 studies the approach was not specified. In the studies that reported Thrombolysis in Cerebral Infarction (TICI) grades, an average of 79% of patients with tandem occlusions were reported to have an outcome of TICI 2b or better. One study found good clinical outcome in 52.5% of the thrombectomy-first group versus 33.3% in the stent-first group, as measured by the modified Rankin Scale (mRS). No study evaluated the difference in time to reperfusion for the anterograde and retrograde approach and its association with clinical outcome. The patient in the illustrative case had AIS and tandem occlusion of the internal carotid and middle cerebral arteries and underwent distal revascularization using a Solitaire stent retrieval device followed by angioplasty and stent treatment of the proximal cervical carotid occlusion. The revascularization was graded as TICI 2b; the postintervention National Institutes of Health Stroke Scale (NIHSS) score was 17, and the discharge NIHSS score was 7. The admitting, postoperative, and 30-day mRS scores were 5, 1, and 1, respectively. CONCLUSIONS In stroke patients with tandem occlusions, distal to proximal revascularization represents a reasonable treatment approach and may offer the advantage of decreased time to reperfusion, which is associated with better functional outcome. Further studies are warranted to determine the best techniques in endovascular therapy to use in this subset of patients in order to improve clinical outcome.
机译：目的串联阻塞继续代表急性缺血性中风（AIS）患者的主要挑战。在没有明确共识或标准指南的情况下，已经报道了近端至远端血运重建的顺行方法以及远端至近端血运重建的逆行方法。方法作者对PubMed数据库进行了全面搜索，以研究包括接受血管内治疗的颈动脉闭塞和串联远端闭塞的患者。他们回顾了用于血管内介入治疗的方法类型和报告的临床结果，重点是血管重建技术。他们还根据自己的经验介绍了AIS并发颈椎近端颈动脉闭塞和大脑中动脉远端闭塞的示例，以概述类似病例的管理难题。结果共鉴定出22项研究，总共790例AIS的串联阻塞患者。十一项研究使用顺行方法，三项研究使用逆行方法，四项研究均使用逆行方法，在四项研究中未指定方法。在报告脑梗塞（TICI）级别溶栓的研究中，据报道，平均79％的串联闭塞患者的预后为TICI 2b或更高。一项研究发现，经改良的兰金量表（mRS）衡量，血栓切除术优先组中52.5％的患者具有良好的临床结果，而支架置入术中组中33.3％的患者具有良好的临床效果。没有研究评估顺行和逆行方法再灌注时间的差异及其与临床结局的关系。在说明性病例中，患者发生了颈内动脉和大脑中动脉的AIS和串联闭塞，并使用Solitaire支架取回设备进行了远端血管再造，然后进行了血管成形术和近端颈动脉闭塞的支架治疗。血运重建被定为TICI 2b。干预后美国国立卫生研究院卒中量表（NIHSS）得分为17，出院NIHSS得分为7。入院，术后和30天的mRS得分分别为5、1和1。结论在患有串联闭塞的中风患者中，远端至近端血运重建代表了一种合理的治疗方法，并且可能提供减少再灌注时间的优点，这与更好的功能预后相关。有必要进行进一步的研究，以确定在该患者亚群中使用的血管内治疗的最佳技术，以改善临床疗效。

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