Sibylle Stampfl
Tandem cervical internal carotid artery/middle cerebral artery occlusion is a relatively frequent finding (10–20%) in patients with acute stroke who undergo endovascular treatment.1 In the literature there were only reports about emergency cervical carotid artery stenting prior to intracranial stroke treatment, but no studies evaluating the combination with intracranial thrombectomy exclusively performed with stent retrievers.2–4 However, stent retrievers are increasingly used due to their ability for rapid flow restoration5 and are current standard practice in our institution. Therefore, it seemed important for us to evaluate the technical feasibility of cervical internal carotid artery stenting in combination with intracranial thrombectomy and the clinical outcome of these patients with acute stroke.
In tandem cervical ICA/MCA occlusions, ICA stent placement is required in most cases, which complicates the procedure and results in a prolonged procedure time until recanalization. However, we found that emergency ICA stent implantation in combination with intracranial thrombectomy could be performed efficiently in most patients. TICI ≥ 2b was reached in 62.5%. The clinical outcome seemed to be acceptable for such a cohort with severe stroke (the median mRS score was 3 after 3 months).
Emergency stent placement poses a challenge regarding antiplatelet therapy, which is required to prevent acute stent thrombosis. During evaluation of our data we noticed that in our series intracranial hemorrhage occurred more frequently (16.6%) than in other endovascular stroke studies.6,7 We supposed that this complication was most likely caused by relatively aggressive antiplatelet therapy with full-dose tirofiban in most of our patients. This finding made us reconsider our antiplatelet therapy in patients with acute stent implantation. At present we administer IV aspirin and clopidogrel via a gastric tube, instead of tirofiban, in order to avoid