CLINICAL STUDY

Endovascular Procedures versus Intravenous Thrombolysis in Stroke with Tandem Occlusion of the Anterior Circulation Serdar Tütüncü, MD, Jan F. Scheitz, MD, Georg Bohner, MD, Jochen B. Fiebach, MD, Matthias Endres, MD, and Christian H. Nolte, MD

ABSTRACT Purpose: Stroke with tandem occlusion within the anterior circulation presents a lower probability of recanalization and good clinical outcome after intravenous (IV) thrombolysis than stroke with single occlusion. The present study describes the impact of endovascular procedures (EPs) compared with IV thrombolysis alone on recanalization and clinical outcome. Materials and Methods: Thirty patients with symptom onset less than 4.5 hours and tandem occlusion within the anterior circulation were analyzed retrospectively. Recanalization was assessed per Thrombolysis In Cerebral Infarction (TICI) classification on computed tomography, magnetic resonance imaging, or digital subtraction angiography within 24 hours. Infarct size was detected on follow-up imaging as a dichotomized variable, ie, more than one third of the territory of the middle cerebral artery. Clinical outcomes were major neurologic improvement, independent outcome (90-d modified Rankin Scale [mRS] score), symptomatic intracerebral hemorrhage (sICH; per European Cooperative Acute Stroke Study criteria), and death within 7 days. Results: Patients treated with EPs (n ¼ 14) were significantly younger and had a history of arterial hypertension more frequently than patients treated with IV thrombolysis alone (n ¼ 16). Recanalization (ie, TICI score 2b/3; EP, 64%; IV, 19%; P ¼ .01), major neurologic improvement (EP, 64%; IV, 19%; P ¼ .01), and independent outcome (mRS score r 2; EP, 54% IV, 13%; P ¼ .02) occurred more often in the EP group, whereas infarct sizes greater than one third of the MCA territory (EP, 43%; IV, 81%; P ¼ .03) were observed less often. Rates of sICH (P ¼ .12) and death within 7 days (P ¼ .74) did not differ significantly. Conclusions: Higher recanalization rate, smaller infarct volume, and better clinical outcome in the EP group should encourage researchers to include this subgroup of patients in prospective randomized trials comparing IV thrombolysis versus EP in stroke.

ABBREVIATIONS CI = confidence interval, EP = endovascular procedure, MCA = middle cerebral artery, mRS = modified Rankin scale, NA = not applicable, NIHSS = National Institutes of Health Stroke Scale, OR = odds ratio, rt-PA = recombinant tissue plasminogen activator, sICH = symptomatic intracerebral hemorrhage, TICI = Thrombolysis In Cerebral Infarction

From the Departments of Neurology (S.T., J.F.S., M.E., C.H.N.) and Radiology (G.B.), Charité–Universitätsmedizin; and Center of Stroke Research (J.F.S., J.B.F., C.H.N.), Berlin, Germany. Received May 25, 2013; final revision received February 9, 2014; accepted February 24, 2014. Address correspondence to S.T., Department of Neurology, Charité–Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; E-mail: [email protected] The study was funded by the German Federal Ministry of Education and Research via grant support to the Center for Stroke Research (Berlin, Germany). S.T. and J.F.S. received travel grants from Boehringer Ingelheim (Ingelheim, Germany). J.B.F. received honoraria from PAION (Aachen, Germany) and Lundbeck Pharma as members of the steering committee or imaging committee. C.H.N. has received speaker honoraria from Boehringer Ingelheim and Pfizer (New York, New York) and research support from the German Ministry of Research and Education. Neither of the other authors has identified a conflict of interest. & SIR, 2014 J Vasc Interv Radiol 2014; XX:]]]–]]] http://dx.doi.org/10.1016/j.jvir.2014.02.027

Among strokes treated with intravenous (IV) thrombolysis, successful recanalization and good clinical outcome occur less often in cases of tandem occlusion (occlusion of ipsilateral extra- and intracranial arteries) than in cases of single intracranial vessel occlusion (1–3). Endovascular procedures (EPs) represent a promising option in patients with large-vessel occlusions (4,5). Recently published prospective randomized trials (6–8) failed to show superiority of EP versus standard medical care with IV recombinant tissue plasminogen activator (rtPA). However, these studies did not include patients with tandem occlusions. Data on patients with tandem occlusions have been limited to a few case reports or small case series that lacked comparison groups (9–12). Therefore, it remains unclear if EP results in a better vascular and clinical outcome in those patients. The aim of the present study is to describe the impact of rescue

2



Tandem-Occlusion Stroke: Endovascular Treatment vs IV Thrombolysis

approaches with EP on radiologic outcomes (intracranial vessel recanalization, infarct size) and clinical outcomes compared with treatment with IV rt-PA alone in patients with stroke with tandem occlusion.

MATERIALS AND METHODS The local ethical committee approved standard qualityassurance measures and allowed publication of the present data.

Study Population Thirty patients with stroke with a symptom onset less than 4.5 hours and proven tandem occlusion of the anterior circulation (eg, occlusion of the ipsilateral extracranial internal carotid artery [ICA] and additionally the intracranial carotid T or middle cerebral artery) were identified in our ongoing thrombolysis registry (13). Vessel occlusions were detected by magnetic resonance (MR) angiography or computed tomographic (CT) angiography. Patients were treated with IV rt-PA alone or with a rescue approach with EPs (IV rt-PA and/or intraarterial [IA] rt-PA and/or mechanical neurothrombectomy). In September 2010, an intradepartmental conference defined the management of severely affected acute stroke cases: CT angiography or MR angiography was made mandatory in all patients presenting within 4.5 hours after the event, and patients with a National Institutes of Health Stroke Scale (NIHSS) score of at least 10 were

Tütüncü et al



JVIR

considered eligible for rt-PA. If the angiography revealed an occlusion of proximal vessels (ICA, carotid T, and/or middle cerebral artery [MCA] main stem), therapy in a rescue approach with EPs was attempted. Therefore, the present study mainly constitutes a before-and-after comparison. Vessel status was assessed by CT angiography or MR angiography performed within 24 hours after the first imaging or by the last series of digital subtraction angiograms after EPs. For each patient, sociodemographic data (age, sex, living conditions) were recorded, as were stroke risk factors (arterial hypertension, diabetes mellitus, hypercholesterolemia, smoking, previous stroke, atrial fibrillation) and other factors potentially associated with vessel recanalization or clinical outcome (onset to treatment time, site of intracranial vessel occlusion, NIHSS score on admission).

Diagnostic Tools Parenchymal and vessel imaging was performed with a 3-T MR scanner and included MR angiography (Tim Trio; Siemens, Erlangen, Germany) or contrastenhanced CT (64-row Sensation 16; Siemens, Erlangen, Germany) with CT angiography. Details of the MR imaging protocol were published previously (14). The TICI score was used to assess the degree and rate of recanalization (15). Clinical outcome was assessed by physicians certified in NIHSS and modified Rankin scale (mRS) scoring. The outcome after 3 months was assessed by mRS by using a standardized questionnaire or a standardized telephone interview (16).

Table 1 . Baseline Characteristics Characteristic Male sex

EP (n ¼ 14) 7 (50)

IV rt-PA Alone (n ¼ 16) 7 (44)

P Value .73

Median age (y)

62 (54–69)

81 (74–88)

o.00

Median NIHSS score Arterial hypertension

19 (15–22) 9 (64)

18 (14–21) 16 (100)

.42 .01

Diabetes mellitus

1 (7)

2 (13)

.63

Atrial fibrillation Hyperlipidemia

5 (36) 6 (43)

8 (50) 5 (31)

.43 .51

Smoking

6 (43)

4 (25)

.30

Previous stroke Coronary heart disease

3 (21) 2 (14)

2 (13) 3 (19)

.64 .74

12 (86) 0

10 (63) 3 (19)

.15 .09

2 (14)

3 (19)

.74

Site of MCA occlusion M1 (main stem) M2/M3 branch Carotid T Left-sided MCA infarction Median onset to IV rt-PA (min) Median onset to endovascular treatment (min) MR as initial imaging modality Admission from nursing home

9 (64) 87 (74–131) 204 (156–229) 7 (50) 0

7 (44) 106 (86–119)

.26 .06

– 13 (81) 2 (13)

.07 .17

Values in parentheses are percentages or interquartile ranges as appropriate. EP ¼ endovascular procedure; IV ¼ intravenous, MCA ¼ middle cerebral artery; NIHSS ¼ National Institutes of Health Stroke Scale; rt-PA ¼ recombinant tissue plasminogen activator.

Volume XX

Table 2 . Detailed Information on Patients who underwent Additional EPs rt-PA Dose (mg)

IV

1

M1

88

2

M1

155

Pt. No.

2b/3

IA

Device Used

Intervention (min)

Etiology

63

10

None

209

Dissection

Balloon angioplasty,

53

17

None

240

Atherothrombotic

Balloon angioplasty,

Intervention

stent

(Intracranial Occlusion)

Periprocedural Complication

Heparin perfusion postprocedure

Yes

No

No

No

Yes

No

Yes

No

(24 h; PTT 60 s) ASA 500 mg, clopidogrel 300



stent

Periprocedural Medication

Month

IV rt-PA (min)

TICI Score



Occlusion Site

Extracranial ICA Occlusion Onset to

Number X

Onset to



Intracranial

mg, heparin

2014

perfusion postprocedure (24 h; PTT 60 s) 3

M1

125

60

10

Penumbra

188

Atherothrombotic

Balloon angioplasty

Heparin perfusion postprocedure

4

M1

150

59

10

Penumbra

198

Atherothrombotic

Balloon angioplasty,

ASA 100 mg, clopidogrel 75

5

M1

85

69

10

None

158

Dissection

Balloon angioplasty

None

Yes

No

6

M1

220

54

0

Penumbra

313

Dissection

Balloon

IA heparin 5,000 IU

No

No

angioplasty None

intraprocedural IA heparin 5,000 IU

Yes

No

(24 h; PTT 60 s)

stent

7

Carotid T

75

70

0

Penumbra

225

Atherothrombotic

mg

intraprocedural 8 9

Carotid T M1

75 107

60 80

30 0

10

M1

53

55

0

11 12

M1 M1

80 70

50 60

13

M1

45

14

M1

89

Penumbra Penumbra,

210 166

Atherothrombotic Atherothrombotic

None None

None None

No No

No No

Trevo

223

Atherothrombotic

Balloon angioplasty,

Heparin perfusion postprocedure

Yes

No

0 0

Trevo Trevo

126 150

Atherothrombotic Atherothrombotic

None None

None None

Yes Yes

No No

81

10

Trevo

141

Atherothrombotic

None

None

Yes

Dissection of

41

0

Trevo

261

Atherothrombotic

None

None

Yes

terminal ICA No

Trevo

stent

(24 h; PTT 60 s)

All patients were treated with IV rt-PA (bridging concept) and had an occlusion of the ipsilateral extracranial ICA. ASA ¼ acetylsalicylic acid; EP ¼ endovascular procedure; IA ¼ intraarterial; ICA ¼ internal carotid artery; IV ¼ intravenous; M1 ¼ main stem of middle cerebral artery; PTT ¼ partial thromboplastin time; rt-PA ¼ recombinant tissue plasminogen activator; TICI ¼ Thrombolysis In Cerebral Infarction. 3

4



Tandem-Occlusion Stroke: Endovascular Treatment vs IV Thrombolysis

Tütüncü et al



JVIR

Table 3 . Radiologic and Clinical Outcomes among Patients Treated with and without EPs Outcome Successful recanalization of MCA

EP (n ¼ 14)

IV rt-PA (n ¼ 16)

P Value

Unadjusted OR

95% CI

9 (64)

3 (19)

o .01

7.80

1.48–41.21





.01





6 (43) 2 (14)

13 (81) 0

.03 .12

5.78 NA

1.12–29.85 NA

TICI score 2b/3 Infarct size 4 1/3 MCA territory sICH (ECASS) Major neurologic improvement

9 (64)

3 (19)

.01

7.80

1.48–41.21

In-hospital mortality (7 d) Independent outcome (90-d mRS score r 2)

2 (14) 7 (54)

3 (19) 2 (13)

.74 .02

0.722 0.12

0.10–5.01 0.02–0.77

Values in parentheses are percentages. CI ¼ confidence interval; ECASS ¼ European Cooperative Acute Stroke Study; EP ¼ endovascular procedure; IV ¼ intravenous; MCA ¼ middle cerebral artery; mRS ¼ modified Rankin scale; NA ¼ not applicable; OR ¼ odds ratio; rt-PA ¼ recombinant tissue plasminogen activator; sICH ¼ symptomatic intracerebral hemorrhage; TICI ¼ Thrombolysis In Cerebral Infarction.

Definition of Radiologic and Clinical Outcomes Recanalization was considered relevant if a TICI score of 2b/3 was detected on follow-up CR or MR angiography or in the last series of digital subtraction angiography in patients treated with a rescue approach. Infarct size was recorded as a dichotomized parameter (ie, more than one third of the MCA territory) (17) on follow-up imaging within 24 hours on CT or MR imaging by a reader blinded to therapy and clinical details. Symptomatic intracerebral hemorrhage (sICH) was defined according to European Cooperative Acute Stroke Study criteria (18). Major neurologic improvement was considered present if the NIHSS score decreased by 8 points or reached 1 or 0 by discharge or 7 days after therapy (19). Mortality was assessed as early if it occurred within 7 days of therapy. Clinical outcome 3 months after stroke was considered independent in the presence of an mRS score of 2 or lower.

Statistical Analysis Patients treated with EPs were compared with patients treated with IV rt-PA alone. Dichotomized and categorized characteristics are expressed as percentages. A two-sided Pearson χ2 test was performed for univariate analyses. Continuous data are presented as medians and interquartile ranges, and the Mann–Whitney U test was applied for univariate analysis. All tests were two-tailed, and statistical significance was determined at an α-level of 0.05. Statistical analyses were performed with SPSS software (version 19; SPSS, Chicago, Illinois) for Windows (Microsoft, Redmond, Washington).

are shown in Table 1. In three cases, balloon angioplasty of the ICA was performed. In four cases, combined balloon angioplasty and stent placement in the ICA was performed. All patients received “bridging” therapy with IV rt-PA. Two types of devices were used for mechanical neurothrombectomy: the Penumbra device (Penumbra, Alameda, California) in six cases, the Trevo device (Concentric Medical, Hertogenbosch, The Netherlands) in five cases, and both in one case. Two patients received IA rt-PA alone without mechanical neurothrombectomy (Table 2). Patients treated with and without additional EPs differed significantly in age (P o .01) and history of arterial hypertension (P ¼ .01). The time from symptom onset to initiation of treatment with IV rt-PA was nonsignificantly shorter in the EP group (P ¼ .06). Successful recanalization of the occluded intracranial artery (TICI score 2b/3; EP, 64%; IV, 19%; P ¼ .01; unadjusted odds ratio [OR], 7.80; 95% confidence interval [CI], 1.48– 41.21), major neurologic improvement (EP, 64%; IV, 19%; P ¼ .01; unadjusted OR, 7.80; 95% CI, 1.48– 41.21), and independent outcome (ie, mRS score r 2; EP, 54%; IV, 13%; P ¼ .02; unadjusted OR, 0.12; 95% CI, 0.02–0.77) were all observed more often in the EP group, whereas infarct sizes greater than one third of the MCA territory (EP, 43%; IV, 81%; P ¼ .03; unadjusted OR, 5.78; 95% CI, 1.22–29.85) were observed less often. There were no significant differences between the two groups in the rates of sICH (EP, 14%; IV, 0%; P ¼ .12) and death within 7 days (EP, 14%; IV, 19%; P ¼ .74) (Table 3).

DISCUSSION RESULTS Thirty patients fulfilled the inclusion criteria. All had an ipsilateral extracranial ICA occlusion. Five patients (17%) had additional carotid T occlusion, 22 (73%) had a proximal middle cerebral artery (ie, M1) occlusion, and three (10%) had a distal MCA occlusion (ie, M2/ M3). Sixteen patients were treated with IV rt-PA alone and 14 were treated with an EP. Baseline characteristics

The findings of the present study suggest that patients with acute stroke with tandem occlusion within the anterior circulation might benefit from additional EPs compared with IV rt-PA administration alone. In this cohort, patients treated with EPs had a higher rate of successful recanalization, smaller infarct size, and better clinical outcome. It is well known that patients with large-vessel or tandem occlusions have a poor rate of

Volume XX



Number X



Month



2014

successful recanalization and good clinical outcome when treated with IV rt-PA alone (1,3,20–24). In contrast, EPs are associated with exceptionally high recanalization rates, especially in patients with large-vessel occlusions (4,5). Recently published prospective randomized trials (6–8) failed to demonstrate superiority of EPs versus standard medical care with IV rt-PA regarding clinical outcome. The Merci thrombectomy device (Concentric Medical) was mostly used in these trials. Data on patients with tandem occlusions were not reported separately. In the present study, the Trevo and Penumbra devices were used. Of note, it has been shown that the use of newer thrombectomy devices (eg, Stent-retriever) is associated with a higher rate of successful recanalization and better clinical outcome compared with the MERCI device (25,26). The results in the EP group are in line with a few published case reports and case series (8,9,27,28) demonstrating a high rate of recanalization and good clinical outcome in patients with tandem occlusions who were treated with EPs, and showed a high rate of successful recanalization and acceptable clinical outcome. Lavallée et al (12) reported better vascular and clinical outcomes in patients treated with EPs (n ¼ 4) than in patients treated with IV rt-PA alone (n ¼ 6) (12). On the contrary, Baumgartner et al (11) reported similar clinical outcomes in IV rt-PA alone and EP treatment groups in a study population of 18 patients with stroke. The advantage of EPs versus IV rt-PA alone in the present nonrandomized, mainly before-and-after comparison was consistent for recanalization rate, infarct size, major neurologic improvement, and clinical outcome at 3 months. Moreover, NIHSS on admission did not differ between groups, and the location of intracranial occlusions in distal branches of the MCA was not significantly more frequent in the IV rt-PA group (P ¼ .08). After IV rt-PA therapy, distal vessel occlusions recanalize more often than proximal occlusions of the MCA (20). The limitations of the present study include the retrospective nature, lack of randomization and a real control group, small sample size, patient heterogeneity, shorter time to IV rt-PA therapy, and younger age in the EP group. These limitations may have influenced recanalization rate and clinical outcome strongly, and therefore the results should be interpreted in light of these limitations. The present study found higher recanalization rates, smaller infarct volumes, and better clinical outcomes after treatment with EPs in patients with tandem occlusion. This will hopefully encourage researchers to plan more prospective randomized trials for this group of patients and to include such patients as subgroups in other larger trials.

REFERENCES 1. 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

2. Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV. 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. 3. Derex L, Nighoghossian N, Hermier M, et al. Influence of pretreatment MRI parameters on clinical outcome, recanalization and infarct size in 49 stroke patients treated by intravenous tissue plasminogen activator. J Neurol Sci 2004; 225:3–9. 4. Gupta R, Tayal AH, Levy EI, et al. Intra-arterial thrombolysis or stent placement during endovascular treatment for acute ischemic stroke leads to the highest recanalization rate: results of a multicenter retrospective study. Neurosurgery 2011; 68:1618–1623. 5. The Penumbra Pivotal Stroke Trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 2009; 40:2761–2768. 6. Broderick JP, Palesch YY, Demchuk AM, et al. Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013; 368: 893–903. 7. Kidwell CS, Jahan R, Gornbein J, et al. MR Rescue Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Eng J Med 2013; 368:914–923. 8. Ciccone A, Valvassori L, Nichelatti M, et al. Synthesis Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013; 368:904–913. 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. 10. Machi P, Lobotesis K, Maldonado IL, et al. Endovascular treatment of tandem occlusions of the anterior cerebral circulation with solitaire FR thrombectomy system. Initial experience. Eur J Radiol 2012; 81: 3479–3484. 11. Baumgartner RW, Georgiadis D, Nedeltchev K, Schroth G, Sarikaya H, Arnold M. Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion. Stroke 2008; 39: e27–e28. 12. Lavallée PC, Mazighi M, Saint-Maurice J, et al. Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion. Stroke 2007; 38:2270–2274. 13. Tütüncü S, Ziegler AM, Scheitz JF, et al. Severe renal impairment is associated with symptomatic intracerebral hemorrhage after thrombolysis for ischemic stroke. Stroke 2013; 44:3217–3219. 14. Hotter B, Pittl S, Ebinger M, et al. Prospective study on the mismatch concept in acute stroke patients within the first 24 h after symptom onset - 1000Plus study. BMC Neurol 2009; 9:60. 15. Qureshi AI. New grading system for angiographic evaluation of arterial occlusions and recanalization response to intra-arterial thrombolysis in acute ischemic stroke. Neurosurgery 2002; 50:1405–1415. 16. Berger K, Weltermann B, Kolominsky-Rabas P, Meves S, Heuschmann P, Böhner J. The reliability of stroke scales. The german version of NIHSS, ESS and Rankin scales. Fortschr Neurol Psychiatr 1999; 67:81–93. 17. Rocco A, Fam G, Sykora M, Diedler J, Nagel S, Ringleb P. Poststroke infections are an independent risk factor for poor functional outcome after three-months in thrombolysed stroke patients. Int J Stroke 2013; 8: 639–644. 18. Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebocontrolled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998; 352:1245–1251. 19. Saposnik G, Di Legge S, Webster F, Hachinski V. Predictors of major neurologic improvement after thrombolysis in acute stroke. Neurology 2005; 65:1169–1174. 20. Bhatia R, Hill MD, Shobha N, et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke 2010; 41: 2254–2258. 21. Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke 2007; 38:948–954. 22. Thomalla G, Kruetzelmann A, Siemonsen S, et al. Clinical and tissue response to intravenous thrombolysis in tandem internal carotid artery/ middle cerebral artery occlusion: an MRI study. Stroke 2008; 39:1616– 1618.

6



Tandem-Occlusion Stroke: Endovascular Treatment vs IV Thrombolysis

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.

Tütüncü et al



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.

Endovascular procedures versus intravenous thrombolysis in stroke with tandem occlusion of the anterior circulation.

Stroke with tandem occlusion within the anterior circulation presents a lower probability of recanalization and good clinical outcome after intravenou...
188KB Sizes 0 Downloads 3 Views