Author + information
- Received January 18, 2018
- Revision received April 23, 2018
- Accepted May 15, 2018
- Published online July 2, 2018.
- Panagiotis Papanagiotou, MD, PhDa,∗ (, )
- Diogo C. Haussen, MDb,
- Francis Turjman, MD, PhDc,
- Julien Labreuche, BSTd,
- Michel Piotin, MD, PhDe,
- Andreas Kastrup, MD, PhDf,
- Henrik Steglich-Arnholm, MDg,
- Markus Holtmannspötter, MDh,
- Christian Taschner, MD, PhDi,
- Sebastian Eiden, MDi,
- Raul G. Nogueira, MDb,
- Maria Boutchakova, MDa,
- Adnan Siddiqui, MD, PhDj,
- Bertrand Lapergue, MD, PhDk,
- Franziska Dorn, MDl,
- Christophe Cognard, MD, PhDm,
- Monika Killer, MDn,
- Salvatore Mangiafico, MDo,
- Marc Ribo, MD, PhDp,
- Marios N. Psychogios, MD, PhDq,
- Alejandro Spiotta, MDr,
- Marc Antoine Labeyrie, MDs,
- Alessandra Biondi, MD, PhDt,
- Mikaël Mazighi, MD, PhDe,
- Sébastien Richard, MD, PhDu,
- René Anxionnat, MD, PhDv,
- Serge Bracard, MDv,
- Benjamin Gory, MD, PhDv,
- on behalf of the TITAN Investigators
- aDepartment of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, Bremen, Germany
- bDepartment of Neurology, Emory University/Grady Memorial Hospital, Atlanta, Georgia
- cDepartment of Interventional Neuroradiology, Hospices Civils de Lyon, Lyon, France
- dUniversity Lille, CHU Lille, Santé publique: épidémiologie et qualité des soins, Lille, France
- eDepartment of Interventional Neuroradiology, Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
- fDepartment of Neurology, Hospital Bremen-Mitte, Bremen, Germany
- gDepartment of Neurology, Rigshospitalet, Copenhagen, Denmark
- hDepartment of Neuroradiology, Rigshospitalet, Copenhagen, Denmark
- iDepartment of Neuroradiology, Medical Center-University of Freiburg, Freiburg, Germany
- jDepartment of Neurosurgery, State University of New York, Buffalo, New York
- kDepartment of Neurology, Stroke Center, Foch Hospital, Suresnes, France
- lDepartment of Neuroradiology, University Hospital of Munich, Munich, Germany
- mDepartment of Neuroradiology, University Hospital of Toulouse, Toulouse, France
- nDepartment of Neurology/Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
- oDepartment of Interventional Neuroradiology, Careggi University Hospital, Florence, Italy
- pDepartment of Neurology, Hospital Vall D’Hebron, Barcelona, Spain
- qDepartment of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
- rDepartment of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
- sDepartment of Interventional Neuroradiology, Lariboisière Hospital, Paris, France
- tDepartment of Neuroradiology and Endovascular Therapeutic, University Hospital of Besançon, Besançon, France
- uDepartment Neurology, Stroke Unit, University Hospital of Nancy, Nancy, France
- vDepartment of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, University of Lorraine, Nancy, France
- ↵∗Address for correspondence:
Dr. Panagiotis Papanagiotou, Clinic for Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Saarland University, St.-Jürgen Strasse 1, 28211 Bremen, Germany.
Objectives The aim of this study was to identify the optimal endovascular approach in patients with acute stroke with tandem lesions.
Background At present, there is no consensus about the ideal technical strategy for the endovascular treatment of patients with acute ischemic stroke with tandem lesions of the extracranial internal carotid artery (ICA) and intracranial cerebral arteries.
Methods This was an international, multicenter registry with a total of 482 patients with acute ischemic stroke and tandem lesions. Patients were treated by intracranial thrombectomy as well as 1 of the following 4 strategies: 1) acute carotid artery stenting of the extracranial ICA with antithrombotic agents; 2) acute carotid artery stenting of the extracranial ICA without antithrombotic agents; 3) balloon angioplasty of the extracranial ICA; and 4) intracranial thrombectomy alone. The main outcome endpoints of the study were the degree of recanalization and the 90-day clinical outcome. The safety endpoints were symptomatic intracerebral hemorrhage and all causes of mortality at 90 days.
Results Using univariate analysis, the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction grades 2B and 3) and favorable clinical outcome after 90 days were significantly higher after acute carotid stenting with antithrombotic therapy and thrombectomy compared with the group with thrombectomy alone. After adjusting for confounding variables, acute stenting with antithrombotic therapy was independently associated with successful recanalization (odds ratio: 2.4; 95% confidence interval: 1.25 to 4.59; p = 0.008). The rates of symptomatic intracerebral hemorrhage and 90-day mortality were comparable among all 4 treatment groups.
Conclusions Acute stenting of the extracranial ICA with antithrombotic therapy in combination with intracranial thrombectomy is associated with higher recanalization rates in treatment of patients with acute stroke with tandem lesions.
Dr. Papanagiotou is a local principal investigator for the SWIFT PRIME study; and has served as a consultant for Penumbra and Johnson & Johnson. Dr. Holtmannspötter has received honoraria for consultancy and proctoring from Medtronic, Stryker, and Microvention. Dr. Nogueira has received honoraria from Stryker Neurovascular for the TREVO 2 trial and DAWN trial, from Medtronic for the SWIFT and SWIFT PRIME trial steering committees, and STAR trial core laboratory, from Penumbra for 3D Separator Trial Executive Committee, and from Neuravi for the ARISE-2 steering committee. Dr. Siddiqui has received grants from the National Institutes of Health, National Institute of Neurological Disorders and Stroke, and National Institute of Biomedical Imaging and Bioengineering, University at Buffalo; personal fees from Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, and Lazarus Effect; and nonfinancial support from Codman & Shurtleff, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra, Stryker, Pulsar Vascular, MicroVention, Lazarus Effect, and Blockade Medical, outside the submitted work. Dr. Spiotta owns stock in Penumbra; and has received honoraria for consultancy and proctoring for Penumbra and Stryker. Dr. Turjman has received honoraria for consultancy and proctoring from Medtronic, Stryker Codman, and Balt. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 18, 2018.
- Revision received April 23, 2018.
- Accepted May 15, 2018.
- 2018 American College of Cardiology Foundation