Zhu François, Bracard Serge, Anxionnat René, Derelle Anne-Laure, Tonnelet Romain, Liao Liang, Mione Gioia, Humbertjean Lisa, Lacour Jean-Christophe, Hossu Gabriela, Anadani Mohammad, Richard Sébastien, Gory Benjamin
Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France.
INSERM U1254, IADI, University of Lorraine, Nancy, France.
Front Neurol. 2019 Mar 11;10:206. doi: 10.3389/fneur.2019.00206. eCollection 2019.
Endovascular therapy has been shown to be an effective and safe treatment for tandem occlusion. The endovascular therapeutic strategies for tandem occlusions strokes have not been adequately evaluated and the best approach is still controversial. The TITAN (Thrombectomy in TANdem occlusions) registry was a result of a collaborative effort to identify the best therapeutic approach for acute ischemic stroke due to tandem lesion. In this review, we aim to summarize the main findings of the TITAN study and discuss the challenges of treatment for tandem occlusion in the era of endovascular thrombectomy. A review of the data from the multicenter international observational and non-randomized TITAN registry was performed. The TITAN registry included acute ischemic stroke patients with tandem lesions (proximal intracranial occlusion and cervical carotid artery occlusion or stenosis>90%) who were treated with thrombectomy with or without carotid artery stenting. Prior intravenous thrombolysis and emergent cervical carotid stenting were associated with higher reperfusion (mTICI 2b-3 and mTICI 3) rates at the end of the intervention. Poor outcome did not occur more frequently after stenting than after conservative treatment of the cervical carotid lesion. Emergent carotid stenting with antithrombotic agents and intracranial thrombectomy yielded higher reperfusion rate and good outcome (90 day mRS 0-2) compared to other strategies (carotid artery stenting and thrombectomy without antithrombotic, angioplasty and thrombectomy, or thrombectomy alone). Pretreatment intravenous thrombolysis was not associated with increased risk of hemorrhagic complications. Likewise, periprocedural unfractionated heparin did not modify the efficacy and safety results. Etiology of carotid artery lesion (atherosclerosis vs. dissection) did not emerge as predictor of outcome or recanalization. Emergent stenting of the cervical carotid lesion with antithrombotic agents in conjunction to thrombectomy appears to be the best treatment strategy for acute ischemic strokes with tandem lesions. These findings will be further investigated in the ongoing randomized controlled TITAN trial.
血管内治疗已被证明是治疗串联闭塞的一种有效且安全的方法。对于串联闭塞性卒中的血管内治疗策略尚未得到充分评估，最佳方法仍存在争议。TITAN（串联闭塞性血栓切除术）注册研究是一项合作努力的结果，旨在确定针对串联病变所致急性缺血性卒中的最佳治疗方法。在本综述中，我们旨在总结TITAN研究的主要发现，并讨论血管内血栓切除术时代串联闭塞治疗面临的挑战。我们对来自多中心国际观察性和非随机TITAN注册研究的数据进行了回顾。TITAN注册研究纳入了患有串联病变（颅内近端闭塞和颈内动脉闭塞或狭窄>90%）的急性缺血性卒中患者，这些患者接受了有或没有颈动脉支架置入的血栓切除术。术前静脉溶栓和急诊颈内动脉支架置入与干预结束时更高的再灌注率（改良脑梗死溶栓分级2b - 3级和3级）相关。与颈内动脉病变保守治疗相比，支架置入后不良结局的发生频率并未更高。与其他策略（无抗血栓药物的颈动脉支架置入和血栓切除术、血管成形术和血栓切除术或单纯血栓切除术）相比，使用抗血栓药物的急诊颈动脉支架置入和颅内血栓切除术产生了更高的再灌注率和良好结局（90天改良Rankin量表评分0 - 2分）。术前静脉溶栓与出血并发症风险增加无关。同样，围手术期普通肝素并未改变疗效和安全性结果。颈动脉病变的病因（动脉粥样硬化与夹层）并未成为结局或再通的预测因素。对于伴有串联病变的急性缺血性卒中，使用抗血栓药物对颈内动脉病变进行急诊支架置入联合血栓切除术似乎是最佳治疗策略。这些发现将在正在进行的随机对照TITAN试验中进一步研究。
