Management and outcome of patients with acute ischemic stroke and tandem carotid occlusion in the ESCAPE-NA1 trial

Martha Marko; Petra Cimflova; Alexandre Y Poppe; Nima Kashani; Nishita Singh; Johanna Ospel; Arnuv Mayank; Brian van Adel; Ryan A McTaggart; Raul G Nogueira; Andrew M Demchuk; Jeremy L Rempel; Manish Joshi; Charlotte Zerna; Bijoy K Menon; Michael Tymianski; Michael D Hill; Mayank Goyal; Mohammed A Almekhlafi; ESCAPE-NA1 investigators

doi:10.1136/neurintsurg-2021-017474

Management and outcome of patients with acute ischemic stroke and tandem carotid occlusion in the ESCAPE-NA1 trial

J Neurointerv Surg. 2022 May;14(5):neurintsurg-2021-017474. doi: 10.1136/neurintsurg-2021-017474. Epub 2021 May 4.

Authors

Martha Marko^{1

2}, Petra Cimflova³, Alexandre Y Poppe^{4

5}, Nima Kashani⁶, Nishita Singh⁷, Johanna Ospel^{8

9}, Arnuv Mayank³, Brian van Adel¹⁰, Ryan A McTaggart¹¹, Raul G Nogueira¹², Andrew M Demchuk¹³, Jeremy L Rempel¹⁴, Manish Joshi⁷, Charlotte Zerna², Bijoy K Menon¹³, Michael Tymianski¹⁵, Michael D Hill¹³, Mayank Goyal¹⁶, Mohammed A Almekhlafi¹⁷; ESCAPE-NA1 investigators

Affiliations

¹ Department of Neurology, Medical University of Vienna, Wien, Austria.
² Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
³ Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
⁴ Department of Neurosciences, Université de Montréal, Montreal, Québec, Canada.
⁵ Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.
⁶ Neuroradiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
⁷ Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.
⁸ Department of Radiology, University Hospital Basel, Basel, Switzerland.
⁹ University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
¹⁰ Neurosurgery, McMaster University Department of Medicine, Hamilton, Ontario, Canada.
¹¹ Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
¹² Emory University School of Medicine, Grady Memorial Hospital Corp, Atlanta, Georgia, USA.
¹³ Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
¹⁴ Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.
¹⁵ NoNO, Toronto, Ontario, Canada.
¹⁶ Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
¹⁷ Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada mohammed.almekhlafi1@ucalgary.ca.

PMID: 33947770
DOI: 10.1136/neurintsurg-2021-017474

Abstract

Background: The optimal treatment and prognosis for stroke patients with tandem cervical carotid occlusion are unclear. We analyzed outcomes and treatment strategies of tandem occlusion patients in the ESCAPE-NA1 trial.

Methods: ESCAPE-NA1 was a multicenter international randomized trial of nerinetide versus placebo in 1105 patients with acute ischemic stroke who underwent endovascular treatment. We defined tandem occlusions as complete occlusion of the cervical internal carotid artery (ICA) on catheter angiography, in addition to a proximal ipsilateral intracranial large vessel occlusion. Baseline characteristics and outcome parameters were compared between patients with tandem occlusions versus those without, and between patients with tandem occlusion who underwent ICA stenting versus those who did not. The influence of tandem occlusions on functional outcome was analyzed using multivariable regression modeling.

Results: Among 115/1105 patients (10.4%) with tandem occlusions, 62 (53.9%) received stenting for the cervical ICA occlusion. Of these, 46 (74.2%) were stented after and 16 (25.8%) before the intracranial thrombectomy. A modified Rankin Score (mRS) of 0-2 at 90 days was achieved in 82/115 patients (71.3%) with tandem occlusions compared with 579/981 (59.5%) patients without tandem occlusions. Tandem occlusion did not impact functional outcome in the adjusted analysis (OR 1.5, 95% CI 0.95 to 2.4). Among the subgroup of patients with tandem occlusion, cervical carotid stenting was not associated with different outcomes compared with no stenting (mRS 0-2: 75.8% vs 66.0%, adjusted OR 2.0, 95% CI 0.8 to 5.1).

Conclusions: Tandem cervical carotid occlusion in patients with acute large vessel stroke did not lower the odds of good functional outcome in our study. Functional outcomes were similar irrespective of the management of the cervical ICA occlusion (stenting vs not stenting).

Keywords: stroke; thrombectomy.

Publication types

Multicenter Study
Randomized Controlled Trial

MeSH terms

Carotid Artery, Internal
Carotid Stenosis* / complications
Carotid Stenosis* / diagnostic imaging
Carotid Stenosis* / surgery
Endovascular Procedures* / adverse effects
Humans
Ischemic Stroke* / diagnostic imaging
Ischemic Stroke* / surgery
Retrospective Studies
Stents / adverse effects
Stroke* / complications
Stroke* / diagnostic imaging
Stroke* / therapy
Thrombectomy
Treatment Outcome