Need for Consensus on Acute Management of Stroke With Tandem Occlusion

Gregory Jacquin, MD

Acute management of tandem occlusion in stroke varies greatly, according to results of an international survey published in Stroke, emphasizing the need for a randomized clinical trial to better understand the benefits of acute stenting of the internal carotid artery.

“The survey was conducted because we are facing a large number of patients suffering acute stroke from a carotid stenosis and who undergo thrombectomy in our own center,” lead author Gregory Jacquin, MD, FRCPC, assistant professor of neurology at the University of Montreal in Quebec, Canada, told NeurologyLive in an interview. “We are regularly facing the dilemma whether or not to treat the carotid that caused the stroke in the same treatment session or not since no dedicated studies have been undertaken that prospectively evaluate the risk-benefit ratio of acute carotid stenting in patients undergoing acute stroke thrombectomy.”

In order to better understand current practice patterns in physicians with stroke expertise, Jacquin and colleagues distributed a survey to stroke specialists associated with the Canadian Stroke Consortium, the Canadian Interventional Neuro Group, the Society of Vascular and Interventional Neurology, and collaborators of the international ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times) trial.

Survey responses from 162 participants (40.1% stroke specialists; 45.7% neurointerventionalists) were recorded and analyzed. Overall, 59.3% of respondents indicated that they consider acute extracranial stenting of the internal carotid artery as a treatment option, while 40.7% reported that they never stent in the acute setting. Notably, no significant differences in practice were observed between groups based on specialty, country of origin, and years of practice.

Factors associated with nonstenting included risk for intracranial hemorrhage associated with antiplatelet therapy (67.9%); risk for acute stent thrombosis (51.9%); and lack of evidence supporting acute stenting (51.2%). Among those inclined to utilize stenting, use of intravenous thrombolysis and associated risk for intracranial hemorrhage would be cause for hesitation (33.3%). Respondents indicated that the retrograde approach of revascularization followed by carotid stenting is most frequently used (65.6%), while dual antiplatelet therapy is most preferred (63.5%).

“The advantage of stenting the carotid occlusion in the same session may spare the patient another intervention such as carotid surgery,” Jacquin said. “On the downside, acute carotid stenting may expose the patient to the risk of procedural complications such as hemorrhagic transformation of the acute stroke.”

Nearly 70% of respondents agreed that there is uncertainty concerning the optimal management of acute stroke caused by tandem occlusion, and 54.3% said they would consider participating in a clinical trial that evaluated the optimal management of tandem occlusion in patients undergoing endovascular thrombectomy.

“Our group is currently in the process of setting up such a trial with possible participation of comprehensive stroke centers across the US and Canada,” Jacquin said. “Interested stroke teams may contact the principal investigator, my colleague Alexandre Poppe, MD, for more information on the EASI-TOC trial.”

REFERENCE

Jacquin G, Poppe AY, Labrie M, et al. Lack of consensus among stroke experts on the optimal management of patients with acute tandem occlusion. Stroke. 2019; Published March 20, 2019. Accessed April 2, 2019.