Endovascular treatment of patients with ischemic stroke in the acute period with tandem occlusions of cerebral arteries

Abstract

Objective — to evaluate the possibilities of endovascular treatment of patients in the acute period of ischemic stroke with tandem occlusions of cerebral arteries, to determine the criteria for choosing the optimal treatment strategy.
Materials and methods. 9 patients with tandem occlusions of the internal carotid artery (ICA) and middle cerebral artery in the acute period of ischemic stroke were treated over the last year. The age of patients was from 36 to 82 years. All patients underwent endovascular thrombectomy using a retrograde approach. Carotid stenting in one session was performed in 3 cases. Recanalization of the occlusion of the ICA was not carried out upon the achievement of good recanalization of the middle cerebral artery and the presence of good bloodflow through the anastomosis of circle of Willis in two cases. Evaluation of the effectiveness of endovascular treatment of patients included angiographic and clinical criteria. A good result was considered when achieving the cerebral artery recanalization level — mTICI 2b-3, eliminating stenosis after carotid stenting, the absence of new ischemic and hemorrhagic foci in the brain, regressing neurological deficit, with a significant decrease in the
NIHSS score, achieving the mRS 0–2 at the time of discharge of the patient and on the 90th day after the operation.
Results. The condition of 9 (77.8 %) patients was good (mRS 0–2) at discharge from the hospital. The level of recanalization of the cerebral arteries in these patients at the end of the operation was mTICI 2b-3. Mortality rate was 11.1 % (1 patient). In this patient, the level of recanalization at the end of the operation was mTICI 2a. The deterioration of the patient's condition and swelling of the brain hemisphere necessitated hemicraniectomy, which did not lead to an improvement in the patient's condition. The condition of another patient, despite the level of cerebral arteries recanalization mTICI 3, which achieved 6 hours after the manifestation of the ischemic stroke symptoms, continued to worsen. Swelling of the brain hemisphere has developed. It should be noted that the initial collateral bloodflow to the basin of the right ICA in this patient was absent (ASITN/SIR 0). Hemicranectomy stabilized the patient's condition. His condition improved at the time of discharge (mRS — 4).
Conclusions. Endovascular treatment of patients in the acute period of ischemic stroke with tandem occlusion of the ICA and the middle cerebral artery is highly effective. The choice of an optimal treatment strategy is determined on the basis of an analysis of angiographic and clinical data. In addition to the successful recanalization of cerebral arteries, the success of treatment is largely determined by minimizing the time to recanalization and the initial state of the collateral bloodflow to the arteries of the occluded arterial basin. In some cases, the achievement of recanalization of the intracranial arteries without recanalization of the ICA in the presence of adequate anastomoses of the circle of Willis is a safe and effective strategy.