Analysis of safety and efficacy of intravenous thrombolysis combined with emergent carotid artery stenting in patients with acute anterior circulation stroke with tandem lesion treated with mechanical thrombectomy / 中国脑血管病杂志

ABSTRACT

Objective: To analyze the safety and efficacy of intravenous thrombolysis(IVT) combined with emergency carotid artery stenting (eCAS) in acute ischemic stroke (AIS) patients with anterior circulation tandem occlusion and treated with mechanical thrombectomy. Methods: From January 2014 to September 2018, a total of 124 consecutive patients diagnosed with AIS with anterior circulation tandem occlusion and treated with mechanical thrombectomy were retrospectively enrolled from Department of Neurology in 5 comprehensive stroke centers. Patients were divided into 4groups according to IVT and eCAS:group A was without IVT and eCAS; group B was eCAS without IVT; group C was IVT without eCAS; group D was IVT combined with eCAS. Baseline and clinical characteristics were documented and compared among the 4 groups. Baseline characteristics included age, gender, risk factors for stroke, good collateral circulation ratio, National Institutes of Health Stroke Scale(NIHSS) score and Alberta stroke program early CT(ASPECT) score, etc. Clinical characteristics included occlusion site of intracranial artery, the degree of extracranial stenosis, etiology of extracranial stenosis, surgical strategy, femoral artery puncture to recanalization time (PTR).medication during hospitalization, etc. The safety and clinical outcomes of the 4 groups were evaluated, including recanalization, symptomatic intracranial hemorrhage, and prognosis. The modified thrombolysis in cerebral infarction score(mTICI) 2b or 3 was considered as successful recanalization. The modified Rankin scale (MRS) score 0-2 at 90 days was considered as favorable functional outcome and MRS score 0-1 was excellent functional outcome. Results: (1) There were no statistically significant differences in age, blood glucose level at admission, onset to femoral artery puncture time, gender, hypertension, diabetes, atrial fibrillation, smoking, good collateral circulation ratio, NIHSS score and ASPECT score among the 4 groups (all P >0. 05). (2) There were no statistically significant differences in occlusion site of intracranial artery, the degree of extracranial stenosis, extracranial stenosis etiology, priority treatment of distal or proximal lesion and PTR time among the 4 groups (all P > 0. 05). (3) In the total of 124 stroke patients with anterior circulation tandem occlusion and treated with mechanical thrombectomy, the rate of successful reperfusion (mTICI class 2b-3) was 75. 8% (94 cases);symptomatic intracranial hemorrhage was 15. 3% (19 cases); favorable functional outcome at 90 days was 48. 4% (60 cases) and excellent functional outcome was 29. 0% (36 cases);the overall mortality rate was 22. 6% (28 cases). The successful recanalization rate of group A, B, and C was 67.4% (31/46), 75. 8% (25/33), and 75. 0% (21/28), respectively. All patients in group D achieved recanalization (17/17). Compared to the group D, the difference was statistically significant in each group(X2 = 6. 831, P = 0. 009; X2 =4. 906, P = 0. 027; X2 =7. 410, P = 0. 006). The excellent functional outcome of group A.B.and C were 21.7% (10/46), 18.2% (6/33) and 35.7% (10/28).respectively. Compared with group D(10/17), the difference of group A or group B was statistically significant (X2 =7. 878, P = 0.005;X2 =8.517, P = 0.004). However.there was no significant difference between group C and group D(X2 =2.288, P=0. 130). There was no significant difference in symptomatic intracranial hemorrhage, favorable functional outcome and overall mortality rate among the 4 groups (all P > 0. 05). Conclusion: For patients with tandem lesion of the anterior circulation and treated with mechanical thrombectomy, IVT combined with eCAS appears to be feasible and safety.