Endovascular Recanalization of Tandem Carotid and MCA Occlusions

Another thing that came up in conference recently was whether, in the case of acute carotid and tandem M1 occlusions, it might be advisable to attempt recanalization via the non-occluded carotid. The rationale was that tunneling through the the occluded carotid can take a long time and is accompanied by heavier antithrombotic exposure, with its attendant bleeding risks, especially after IV tPA. Putting the guide wire up the non-occluded carotid and across the anterior communicator could allow faster access to the offending M1 occlusion with less antithrombotic exposure.

I asked one of our neuroendovascular colleagues about this option, and the reply was that such an approach has the disadvantage of putting the healthy brain hemisphere at risk (via thromboembolism, vessel perforation, etc.) In this person’s opinion, its better to keep the cerebral procedural risks confined to the infarcting hemisphere if possible.

The literature on acute carotid revascularization is confined to case series. See this and maybe this.

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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3 Responses to Endovascular Recanalization of Tandem Carotid and MCA Occlusions

  1. Ahsan Sattar says:

    Thanks for sharing those papers. An important factor which I believe determines the final outcome is door to recanalization time which in our case was almost close to 10 hours.

    • Justin A. Sattin says:

      Yes. Off-hand, I know of two papers addressing that issue. This one looks at stroke onset-to-procedure termination time and found that after 6-7 hours, outcomes in IA-treated subjects with successful reperfusion were equivalent to those who weren’t reperfused.

      This one looks at procedure time and suggests that procedures accomplished in < 30 minutes were associated with more favorable outcomes as compared to > 30 minutes. The latter patients didn’t do any better than the placebo arm of the PROACT II trial.

  2. Khalid Alsherbini says:

    in regard to that same case , one thing we discussed if the CT/CTP data needed before endovascular therapy. I came across this article which was published in Neurocritical care Journal Nov 1st 2012 ” Agreement in Endovascular thrombolysis patient selection on interpretation of presenting CT and CTP changes ” by Ameer E.Hassan et al. , essentially they gave 5 stroke/endovascular trained neurologist 25 cases of ischemic stroke ” ER presentation, CT , CTP , last known well ” , and asked them to select patient for endovascular therapy independently based initially of CT and then CTP , and they presented the same information to them again in 2 weeks, what they found is that the Kappa value ” which my understanding how strongly they agree ” was 0.43 for CT scan ” considered moderate agreement ” , and was 0.29 ” fair agreement” based on CT perfusion data . and the worst was the intra-rater agreement which was 0.14 which is “poor agreement” . and they concluded that there is considerable lack of agreement even among stroke neurologist in selecting patient for endovascular therapy even for CT perfusion.

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