Mbabuike Nnenna, Gassie Kelly, Brown Benjamin, Miller David A, Tawk Rabih G
Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida.
Neurosurg Focus. 2017 Apr;42(4):E15. doi: 10.3171/2017.1.FOCUS16521.
OBJECTIVE Tandem occlusions continue to represent a major challenge in patients with acute ischemic stroke (AIS). The anterograde approach with proximal to distal revascularization as well as the retrograde approach with distal to proximal revascularization have been reported without clear consensus or standard guidelines. METHODS The authors performed a comprehensive search of the PubMed database for studies including patients with carotid occlusions and tandem distal occlusions treated with endovascular therapy. They reviewed the type of approach employed for endovascular intervention and clinical outcomes reported with emphasis on the revascularization technique. They also present an illustrative case of AIS and concurrent proximal cervical carotid occlusion and distal middle cerebral artery occlusion from their own experience in order to outline the management dilemma for similar cases. RESULTS A total of 22 studies were identified, with a total of 790 patients with tandem occlusions in AIS. Eleven studies used the anterograde approach, 3 studies used the retrograde approach, 4 studies used both, and in 4 studies the approach was not specified. In the studies that reported Thrombolysis in Cerebral Infarction (TICI) grades, an average of 79% of patients with tandem occlusions were reported to have an outcome of TICI 2b or better. One study found good clinical outcome in 52.5% of the thrombectomy-first group versus 33.3% in the stent-first group, as measured by the modified Rankin Scale (mRS). No study evaluated the difference in time to reperfusion for the anterograde and retrograde approach and its association with clinical outcome. The patient in the illustrative case had AIS and tandem occlusion of the internal carotid and middle cerebral arteries and underwent distal revascularization using a Solitaire stent retrieval device followed by angioplasty and stent treatment of the proximal cervical carotid occlusion. The revascularization was graded as TICI 2b; the postintervention National Institutes of Health Stroke Scale (NIHSS) score was 17, and the discharge NIHSS score was 7. The admitting, postoperative, and 30-day mRS scores were 5, 1, and 1, respectively. CONCLUSIONS In stroke patients with tandem occlusions, distal to proximal revascularization represents a reasonable treatment approach and may offer the advantage of decreased time to reperfusion, which is associated with better functional outcome. Further studies are warranted to determine the best techniques in endovascular therapy to use in this subset of patients in order to improve clinical outcome.
目的 串联闭塞仍然是急性缺血性卒中（AIS）患者面临的一项重大挑战。已报道了从近端到远端血运重建的顺行方法以及从远端到近端血运重建的逆行方法，但尚无明确的共识或标准指南。方法 作者对PubMed数据库进行了全面检索，以查找包括接受血管内治疗的颈动脉闭塞和串联远端闭塞患者的研究。他们回顾了用于血管内介入的方法类型以及所报告的临床结果，重点是血运重建技术。他们还根据自身经验介绍了一例AIS合并近端颈内动脉闭塞和远端大脑中动脉闭塞的病例，以概述类似病例的管理困境。结果 共确定了22项研究，总计790例AIS串联闭塞患者。11项研究采用顺行方法，3项研究采用逆行方法，4项研究同时采用两种方法，4项研究未明确方法。在报告脑梗死溶栓（TICI）分级的研究中，据报道平均79%的串联闭塞患者达到TICI 2b级或更好的结果。一项研究发现，以改良Rankin量表（mRS）衡量，血栓切除术优先组52.5%的患者临床结果良好，而支架优先组为33.3%。没有研究评估顺行和逆行方法在再灌注时间上的差异及其与临床结果的关联。该病例中的患者患有AIS以及颈内动脉和大脑中动脉串联闭塞，使用Solitaire支架取栓装置进行了远端血运重建，随后对近端颈内动脉闭塞进行了血管成形术和支架治疗。血运重建分级为TICI 2b；干预后美国国立卫生研究院卒中量表（NIHSS）评分为17分，出院时NIHSS评分为7分。入院时、术后和30天的mRS评分分别为5分、1分和1分。结论 在串联闭塞的卒中患者中，从远端到近端的血运重建是一种合理的治疗方法，并可能具有减少再灌注时间的优势，这与更好的功能结局相关。有必要进行进一步研究以确定用于这部分患者的血管内治疗的最佳技术，以改善临床结果。
