Endovascular Treatment of Tandem Internal Carotid and Middle Cerebral Artery Occlusions

Objective—Extracranial internal carotid artery (ICA) angioplasty and intracranial thrombectomy may be a safe and efficacious therapeutic option for recanalization of a subset of arterial occlusions termed tandem occlusions of Internal carotid artery and Middle cerebral artery (TIM). Background—Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant ICA occlusion and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. We report our experience on acute ischemic stroke patients with TIM occlusion treated with extracranial ICA angioplasty/stenting and intracranial thrombectomy and/or standard intravenous thrombolysis. Design/Methods—A retrospective analysis of 7 patients from our stroke database was done. 6 patients of the 7 patients were treated with extracranial ICA angioplasty and intracranial thrombectomy and/or intravenous thrombolysis. We examined early neurological improvement (defined by a reduction of National Institutes of Health Stroke Scale (NIHSS) > 8 points). We also evaluated the rate of successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2b or 3. Results—All but one of the 6 treated patients achieved a TICI score of 2b or 3 signifying successful recanalization. In addition, treated patients had an early reduction of their NIHSS by greater than 8 points. The 1 patient who did not to achieve TICI 2b or 3 also failed to show early neurological improvement. Four of the treated patients had a follow up NIHSS at 90 days of 1 or less and mRS at 90 days of 0. Conclusions—In cases of tandem occlusions of ICA and MCA, multimodal therapy consistent of intravenous thrombolysis and/or extracranial ICA stenting and intracranial thrombectomy to achieve recanalization may be a safe and efficacious therapeutic option for recanalization. Further prospective studies are warranted.