1170
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Commentary: Interventions in Stroke with Tandem Occlusion
23. Mendonça N, Rodriguez-Luna D, Rubiera M, et al. Predictors of tissuetype plasminogen activator nonresponders according to location of vessel occlusion. Stroke 2012; 43:417–421. 24. Riedel CH, Zimmermann P, Jensen-Kondering U, Stingele R, Deuschl G, Jansen O. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke 2011; 42:1775–1777. 25. Nogueira RG, Lutstep HL, Grupta R, et al. TREVO 2 Trialists. Trevo versus Merci retrievers for thrombectomy revascularization of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomized trial. Lancet 2012; 380:1231–1240.
Bruno and Meyers
’
JVIR
26. Saver JL, Jahan R, Levy EI, et al. SWIFT Trialists. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 2012; 380:1241–1249. 27. Dababneh H, Guerrero WR, Khanna A, Hoh BL, Mocco J. Management of tandem occlusion stroke with endovascular therapy. Neurosurg Focus 2012; 32:E16. 28. Cohen JE, Gomori M, Rajz G, et al. Emergent stent-assisted angioplasty of extracranial internal carotid artery and intracranial stent-based thrombectomy in acute tandem occlusive disease: technical considerations. J Neurointerv Surg 2012; 5:440–446.
INVITED COMMENTARY
Endovascular Procedures versus Intravenous Thrombolysis in Stroke Patients with Tandem Occlusion of the Anterior Circulation Charles A. Bruno, DO, and Philip M. Meyers, MD ABBREVIATIONS IV = intravenous, rt-PA = recombinant tissue plasminogen activator
Stroke is a devastating disease that affects more than 795,000 Americans each year and costs the health care system an estimated $36.5 billion annually (1). In the past, treatment of acute ischemic stroke was essentially based on damage control and consisted of physical and occupational therapy to maximize function in the setting of permanent neurologic deficits. The management of acute ischemic stroke has advanced greatly during the past two decades with the introduction of novel pharmacologic and endovascular therapies aimed at reperfusion of ischemic brain. The first major advancement in the treatment of acute ischemic stroke came in 1996, with the United States Food and Drug Administration approval of intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) when given within 3 hours of symptom onset (2). The drug showed a modest improvement in neurologic From the Departments of Radiology and Neurological Surgery and Neurological Institute, New York–Presbyterian University Hospital of Columbia and Cornell, Columbia University College of Physicians and Surgeons, 710 W. 168th St., Room 428, New York, NY 10032. Received March 21, 2014; final revision received March 22, 2014; accepted March 22, 2014. Address correspondence to P.M.M.; E-mail: [email protected] Neither of the authors has identified a conflict of interest. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1170–1171 http://dx.doi.org/10.1016/j.jvir.2014.03.024
deficit by 90 days, particularly in patients with strokes of lesser severity. The introduction of IV rt-PA was a landmark development that paved the way for future therapies. Since that time, endovascular interventions targeted at improving patient outcomes have been studied. Today, numerous endovascular techniques and devices are available in the interventionalists’ armamentarium. Early reperfusion is the basis of effective therapy for acute ischemic stroke. Restoration of blood flow results in salvage of ischemic penumbra, reduction of infarct volume, and ultimately better clinical outcomes. Unfortunately, patients with large-vessel occlusions have dismal recanalization rates with standard-of-care therapy (ie, IV rt-PA), ranging from 10% for internal carotid artery occlusion to 30% for proximal middle cerebral artery occlusion (3–5). Patients with tandem vessel occlusion (ie, proximal extracranial occlusion in conjunction with an intracranial occlusion) have even lower recanalization rates with IV therapy. Therefore, there is a need for endovascular procedures that can safely and effectively aid in revascularization. Tütüncü and coworkers (6) examined 30 patients with ipsilateral internal carotid artery occlusion and concomitant intracranial occlusion. Fourteen patients underwent endovascular treatment with mechanical therapy (Penumbra device [Penumbra, Alameda, California] or Trevo device [Concentric Medical, Hertogenbosch, The Netherlands]) or pharmacologic therapy
Volume 25
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Number 8
’
August
’
2014
(intraarterial rt-PA) in addition to IV rt-PA. Sixteen patients received IV rt-PA alone. To our knowledge, this is the first report to compare endovascular therapy versus IV rt-PA in this subset of patients. The authors were able to demonstrate several things. First, superior recanalization rates were seen in the endovascular treatment group. The number of cases in which a Thrombolysis In Cerebral Infarction score of 2b/3 was achieved was dramatically higher in the endovascular treatment group compared with the IV rt-PA group (64% vs 19%; P ¼ .01). This finding is similar to those of previously published reports (7,8). In the endovascular treatment group, a Thrombolysis In Cerebral Infarction score of 2b/3 was not achieved in four patients (6). Of those four, only one was treated with the Trevo device, whereas the other three were treated with IA rt-PA (n ¼ 1) or the Penumbra system (n ¼ 3), both of which showed inferior recanalization rates compared with stent retrievers. The authors were also able to demonstrate better clinical outcomes (ie, modified Rankin scale score r 2) in the endovascular treatment group (54% vs 13%; P ¼ .02), which is comparable to other studies of patients with tandem lesions (7,9). Finally, patients in the endovascular treatment group showed smaller infarct sizes on follow-up imaging (6). The study (6) is not without some shortcomings. First, the authors do not describe the technique(s) used to achieve revascularization. What approach was used to recanalize the occluded vessels? Was a retrograde approach used (ie, treatment of the intracranial lesion followed by treatment of the extracranial lesion), or an antegrade approach? What were the technical limitations encountered in these procedures, if any? Another issue with retrospective series is the lack of randomization: How do we measure the effect the authors describe? Finally, the time to IV rt-PA therapy in the endovascular treatment group was shorter than in the noninterventional group, which
1171
may have influenced recanalization rates and clinical outcomes. Endovascular treatment of acute ischemic stroke is an evolving, yet still controversial, procedure in 2014. Prospective studies and metaanalyses of previously published studies are needed to help identify subgroups of patients who would benefit from endovascular therapy, including those with tandem lesions. Future studies that include analysis of this and other subgroups are needed to verify clinical benefit of stroke intervention.
REFERENCES 1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 2014; 129:e28–e292. 2. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995; 333:1581–1587. 3. Wolpert SM, Bruckmann H, Greenlee R, Wechsler L, Pessin MS, del Zoppo GJ. Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. The rt-PA Acute Stroke Study Group. AJNR Am J Neuroradiol 1993; 14:3–13. 4. Rubiera M, Ribo M, Delgado-Mederos R, et al. Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke 2006; 37:2301–2305. 5. Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV; CLOTBUST Collaborators. Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke 2005; 36:869–871. 6. Tütüncü S, Scheitz JF, Bohner G, Fiebach JB, Endres M, Nolte CH. Endovascular procedures versus intravenous thrombolysis in stroke with tandem occlusion of the anterior circulation. J Vasc Interv Radiol 2014; 25: 1175–11780. 7. Puri AS, Kühn AL, Kwon HJ, et al. Endovascular treatment of tandem vascular occlusions in acute ischemic stroke. J Neurointerv Surg 2014, http://dx.doi.org/10.1136/neurintsurg-2013-011010. 8. Dababneh H, Guerrero WR, Khanna A, Hoh BL, Mocco J. Management of tandem occlusion stroke with endovascular therapy. Neurosurg Focus 2012; 32:E16. 9. Malik AM, Vora NA, Lin R, et al. Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary singlecenter experience. Stroke 2011; 42:1653–1657.
’
Commentary: Interventions in Stroke with Tandem Occlusion
23. Mendonça N, Rodriguez-Luna D, Rubiera M, et al. Predictors of tissuetype plasminogen activator nonresponders according to location of vessel occlusion. Stroke 2012; 43:417–421. 24. Riedel CH, Zimmermann P, Jensen-Kondering U, Stingele R, Deuschl G, Jansen O. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke 2011; 42:1775–1777. 25. Nogueira RG, Lutstep HL, Grupta R, et al. TREVO 2 Trialists. Trevo versus Merci retrievers for thrombectomy revascularization of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomized trial. Lancet 2012; 380:1231–1240.
Bruno and Meyers
’
JVIR
26. Saver JL, Jahan R, Levy EI, et al. SWIFT Trialists. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 2012; 380:1241–1249. 27. Dababneh H, Guerrero WR, Khanna A, Hoh BL, Mocco J. Management of tandem occlusion stroke with endovascular therapy. Neurosurg Focus 2012; 32:E16. 28. Cohen JE, Gomori M, Rajz G, et al. Emergent stent-assisted angioplasty of extracranial internal carotid artery and intracranial stent-based thrombectomy in acute tandem occlusive disease: technical considerations. J Neurointerv Surg 2012; 5:440–446.
INVITED COMMENTARY
Endovascular Procedures versus Intravenous Thrombolysis in Stroke Patients with Tandem Occlusion of the Anterior Circulation Charles A. Bruno, DO, and Philip M. Meyers, MD ABBREVIATIONS IV = intravenous, rt-PA = recombinant tissue plasminogen activator
Stroke is a devastating disease that affects more than 795,000 Americans each year and costs the health care system an estimated $36.5 billion annually (1). In the past, treatment of acute ischemic stroke was essentially based on damage control and consisted of physical and occupational therapy to maximize function in the setting of permanent neurologic deficits. The management of acute ischemic stroke has advanced greatly during the past two decades with the introduction of novel pharmacologic and endovascular therapies aimed at reperfusion of ischemic brain. The first major advancement in the treatment of acute ischemic stroke came in 1996, with the United States Food and Drug Administration approval of intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) when given within 3 hours of symptom onset (2). The drug showed a modest improvement in neurologic From the Departments of Radiology and Neurological Surgery and Neurological Institute, New York–Presbyterian University Hospital of Columbia and Cornell, Columbia University College of Physicians and Surgeons, 710 W. 168th St., Room 428, New York, NY 10032. Received March 21, 2014; final revision received March 22, 2014; accepted March 22, 2014. Address correspondence to P.M.M.; E-mail: [email protected] Neither of the authors has identified a conflict of interest. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1170–1171 http://dx.doi.org/10.1016/j.jvir.2014.03.024
deficit by 90 days, particularly in patients with strokes of lesser severity. The introduction of IV rt-PA was a landmark development that paved the way for future therapies. Since that time, endovascular interventions targeted at improving patient outcomes have been studied. Today, numerous endovascular techniques and devices are available in the interventionalists’ armamentarium. Early reperfusion is the basis of effective therapy for acute ischemic stroke. Restoration of blood flow results in salvage of ischemic penumbra, reduction of infarct volume, and ultimately better clinical outcomes. Unfortunately, patients with large-vessel occlusions have dismal recanalization rates with standard-of-care therapy (ie, IV rt-PA), ranging from 10% for internal carotid artery occlusion to 30% for proximal middle cerebral artery occlusion (3–5). Patients with tandem vessel occlusion (ie, proximal extracranial occlusion in conjunction with an intracranial occlusion) have even lower recanalization rates with IV therapy. Therefore, there is a need for endovascular procedures that can safely and effectively aid in revascularization. Tütüncü and coworkers (6) examined 30 patients with ipsilateral internal carotid artery occlusion and concomitant intracranial occlusion. Fourteen patients underwent endovascular treatment with mechanical therapy (Penumbra device [Penumbra, Alameda, California] or Trevo device [Concentric Medical, Hertogenbosch, The Netherlands]) or pharmacologic therapy
Volume 25
’
Number 8
’
August
’
2014
(intraarterial rt-PA) in addition to IV rt-PA. Sixteen patients received IV rt-PA alone. To our knowledge, this is the first report to compare endovascular therapy versus IV rt-PA in this subset of patients. The authors were able to demonstrate several things. First, superior recanalization rates were seen in the endovascular treatment group. The number of cases in which a Thrombolysis In Cerebral Infarction score of 2b/3 was achieved was dramatically higher in the endovascular treatment group compared with the IV rt-PA group (64% vs 19%; P ¼ .01). This finding is similar to those of previously published reports (7,8). In the endovascular treatment group, a Thrombolysis In Cerebral Infarction score of 2b/3 was not achieved in four patients (6). Of those four, only one was treated with the Trevo device, whereas the other three were treated with IA rt-PA (n ¼ 1) or the Penumbra system (n ¼ 3), both of which showed inferior recanalization rates compared with stent retrievers. The authors were also able to demonstrate better clinical outcomes (ie, modified Rankin scale score r 2) in the endovascular treatment group (54% vs 13%; P ¼ .02), which is comparable to other studies of patients with tandem lesions (7,9). Finally, patients in the endovascular treatment group showed smaller infarct sizes on follow-up imaging (6). The study (6) is not without some shortcomings. First, the authors do not describe the technique(s) used to achieve revascularization. What approach was used to recanalize the occluded vessels? Was a retrograde approach used (ie, treatment of the intracranial lesion followed by treatment of the extracranial lesion), or an antegrade approach? What were the technical limitations encountered in these procedures, if any? Another issue with retrospective series is the lack of randomization: How do we measure the effect the authors describe? Finally, the time to IV rt-PA therapy in the endovascular treatment group was shorter than in the noninterventional group, which
1171
may have influenced recanalization rates and clinical outcomes. Endovascular treatment of acute ischemic stroke is an evolving, yet still controversial, procedure in 2014. Prospective studies and metaanalyses of previously published studies are needed to help identify subgroups of patients who would benefit from endovascular therapy, including those with tandem lesions. Future studies that include analysis of this and other subgroups are needed to verify clinical benefit of stroke intervention.
REFERENCES 1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 2014; 129:e28–e292. 2. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995; 333:1581–1587. 3. Wolpert SM, Bruckmann H, Greenlee R, Wechsler L, Pessin MS, del Zoppo GJ. Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. The rt-PA Acute Stroke Study Group. AJNR Am J Neuroradiol 1993; 14:3–13. 4. Rubiera M, Ribo M, Delgado-Mederos R, et al. Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke 2006; 37:2301–2305. 5. Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV; CLOTBUST Collaborators. Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke 2005; 36:869–871. 6. Tütüncü S, Scheitz JF, Bohner G, Fiebach JB, Endres M, Nolte CH. Endovascular procedures versus intravenous thrombolysis in stroke with tandem occlusion of the anterior circulation. J Vasc Interv Radiol 2014; 25: 1175–11780. 7. Puri AS, Kühn AL, Kwon HJ, et al. Endovascular treatment of tandem vascular occlusions in acute ischemic stroke. J Neurointerv Surg 2014, http://dx.doi.org/10.1136/neurintsurg-2013-011010. 8. Dababneh H, Guerrero WR, Khanna A, Hoh BL, Mocco J. Management of tandem occlusion stroke with endovascular therapy. Neurosurg Focus 2012; 32:E16. 9. Malik AM, Vora NA, Lin R, et al. Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary singlecenter experience. Stroke 2011; 42:1653–1657.
