Endovascular Therapy of Anterior Circulation Tandem Occlusions
Authors: Anadani Mohammad , Marnat Gaultier , Consoli Arturo , Papanagiotou Panagiotis , Nogueira Raul G. , Siddiqui Adnan , Ribo Marc , Spiotta Alejandro M. , Bourcier Romain , Kyheng Maeva , Labreuche Julien , de Havenon Adam , Sibon Igor , Dargazanli Cyril , Arquizan Caroline , Cognard Christophe , Olivot Jean-Marc , Anxionnat René , Audibert Gérard , Mazighi Mikaël , Blanc Raphaël , Lapergue Bertrand , Richard Sébastien , Gory Benjamin ,   for the TITAN and ETIS Registry Investigators, Turjman Francis , Piotin Michel , Steglich-Arnholm Henrik , Holtmannspötter Markus , Taschner Christian , Eiden Sebastian , Haussen Diogo C. , Boutchakova Maria , Dorn Franziska , Killer-Oberpfalzer Monika , Mangiafico Salvatore , Psychogios Marios N. , Labeyrie Marc-Antoine , Biondi Alessandra , Bracard Serge , Grossberg Jonathan Andrew , Guenego Adrien , Darcourt Julien , Vukasinovic Isabelle , Pomero Elisa , Davies Jason , Renieri Leonardo , Hecker Corentin , Muchada Maria Muchada , Rodesch Georges , Houdart Emmanuel , Lockau Johanna , Kastrup Andreas , Redjem Hocine , Behme Daniel , Shallwani Hussain , Christopher Maurer , Mione Gioia , Humbertjean Lisa , Riou-Comte Nolwenn , Zhu François , Derelle Anne-Laure , Liao Liang , Piotin Michel , Redjem Hocine , Escalard Simon , Maïer Benjamin , Desilles Jean-Philippe , Ciccio Gabriele , Smajda Stanislas , Obadia Mikael , Sabben Candice , Corabianu Ovide , de Broucker Thomas , Smadja Didier , Alamowitch Sonia , Ille Olivier , Manchon Eric , Garcia Pierre-Yves , Taylor Guillaume , Maacha Malek Ben , Wang Adrien , Evrard Serge , Tchikviladze Maya , Ajili Nadia , Weisenburger David , Gorza Lucas , Coskun Oguzhan , Di Maria Federico , Rodesh Georges , Leguen Morgan , Gratieux Julie , Pico Fernando , Rakotoharinandrasana Haja , Tassan Philippe , Poll Roxanna , Marinier Sylvie , Gariel Florent , Barreau Xavier , Berge Jérôme , Veunac Louis , Menegon Patrice , Lucas Ludovic , Olindo Stéphane , Renou Pauline , Sagnier Sharmila , Poli Mathilde , Debruxelles Sabrina , Tourdias Thomas , Liegey Jean-Sebastien , Detraz Lili , Daumas-Duport Benjamin , Alexandre Pierre-Louis , Roy Monica , Lenoble Cédric , L’allinec Vincent , Girot Jean-Baptiste , Desal Hubert , Bechiri Fatiha , Bracard Serge , Braun Marc , Derelle Anne-Laure , Tonnelet Romain , Liao Liang , Zhu François , Schmitt Emmanuelle , Planel Sophie , Humbertjean Lisa , Mione Gioia , Lacour Jean-Christophe , Hossu Gabriela , Beaumont Marine , Bailang Mitchelle , Reitter Marie , Masson Agnès , Alb Lionel , Tabarna Adriana , Voicu Marcela , Podar Iona , Brezeanu Madalina , Guy Sarah , Costalat Vincent , Gascou Grégory , Lefèvre Pierre-Henri , Derraz Imad , Riquelme Carlos , Gaillard Nicolas , Mourand Isabelle , Corti Lucas 
Published: August 2021

Background and Purpose:
Endovascular therapy for tandem occlusion strokes of the anterior circulation is an effective and safe treatment. The best treatment approach for the cervical internal carotid artery (ICA) lesion is still unknown. In this study, we aimed to compare the functional and safety outcomes between different treatment approaches for the cervical ICA lesion during endovascular therapy for acute ischemic strokes due to tandem occlusion in current clinical practice.

Methods:
Individual patients’ data were pooled from the French prospective multicenter observational ETIS (Endovascular Treatment in Ischemic Stroke) and the international TITAN (Thrombectomy in Tandem Lesions) registries. TITAN enrolled patients from January 2012 to September 2016, and ETIS from January 2013 to July 2019. Patients with acute ischemic stroke due to anterior circulation tandem occlusion who were treated with endovascular therapy were included. Patients were divided based on the cervical ICA lesion treatment into stent and no-stent groups. Outcomes were compared between the two treatment groups using propensity score methods.

Results:

A total of 603 patients were included, of whom 341 were treated with acute cervical ICA stenting. In unadjusted analysis, the stent group had higher rate of favorable outcome (90-day modified Rankin Scale score, 0–2; 57% versus 45%) and excellent outcome (90-day modified Rankin Scale score, 0–1; 40% versus 27%) compared with the no-stent group. In inverse probability of treatment weighting propensity score–adjusted analyses, stent group had higher odds of favorable outcome (adjusted odds ratio, 1.09 [95% CI, 1.01–1.19];
P
=0.036) and successful reperfusion (modified Thrombolysis in Cerebral Ischemia score, 2b-3; adjusted odds ratio, 1.19 [95% CI, 1.11–1.27];
P
<0.001). However, stent group had higher odds of any intracerebral hemorrhage (adjusted odds ratio, 1.10 [95%, 1.02–1.19];
P
=0.017) but not higher rate of symptomatic intracerebral hemorrhage or parenchymal hemorrhage type 2. Subgroup analysis demonstrated heterogeneity according to the lesion type (atherosclerosis versus dissection;
P
for heterogeneity, 0.01), and the benefit from acute carotid stenting was only observed for patients with atherosclerosis.

Conclusions:
Patients treated with acute cervical ICA stenting for tandem occlusion strokes had higher odds of 90-day favorable outcome, despite higher odds of intracerebral hemorrhage; however, most of the intracerebral hemorrhages were asymptomatic.