STRATIS Tandem Lesion
Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke
Clinical Question
In patients with acute ischemic stroke due to tandem occlusions of the extracranial carotid artery and intracranial large vessels, what are the clinical and procedural outcomes associated with acute stenting of the extracranial lesion during thrombectomy compared to no stenting?
Bottom Line
In this large, prospective registry of acute stroke patients with tandem occlusions, acute stenting of the extracranial carotid artery stenosis during thrombectomy was associated with significantly better functional outcomes at 90 days compared to no stenting, with no significant difference in safety outcomes such as mortality or symptomatic hemorrhage.
Major Points
- The STRATIS registry analyzed 147 patients with tandem occlusions from a cohort of 984 patients undergoing neurothrombectomy.
- Acute stenting of the extracranial carotid lesion was performed in 80 (54%) of these patients.
- Patients who underwent acute stenting had a significantly higher rate of good functional outcomes (mRS 0-2) at 90 days compared to those who did not receive a stent (68.5% vs 42.2%; P=0.003).
- There were no significant differences in mortality or symptomatic intracranial hemorrhage between the stenting and no-stenting groups.
- After adjusting for baseline covariates, acute stenting remained an independent predictor of good outcomes.
- A history of atrial fibrillation was associated with a lower likelihood of receiving an acute stent.
Design
Study Type: Prospective, multicenter, nonrandomized, observational registry.
Randomization:
Blinding: Not applicable (observational registry).
Enrollment Period: August 2014 to June 2016.
Follow-up Duration: 90 days.
Centers: 55
Countries: United States
Sample Size: 147
Analysis: Univariate and multivariable logistic regression.
Inclusion Criteria
- Confirmed symptomatic large vessel intracranial occlusion in the anterior circulation (ICA, M1, or M2).
- NIHSS >8.
- Baseline mRS of 0-1.
- Treatment within 8 hours of symptom onset.
- Tandem lesions defined as an extracranial internal carotid occlusive or stenotic lesion accompanying the principal intracranial lesion.
Exclusion Criteria
- Not explicitly detailed for the tandem cohort, but based on the main STRATIS registry criteria.
Arms
| Field | Control | Acute Stent |
|---|---|---|
| Intervention | Mechanical thrombectomy for intracranial occlusion without acute stenting of the extracranial carotid lesion. A subset of these patients (n=43) received angioplasty alone. | Mechanical thrombectomy for intracranial occlusion with acute stenting of the extracranial carotid lesion. |
| Duration | 90-day follow-up | 90-day follow-up |
Outcomes
| Outcome | Type | Control | Intervention | HR / OR / RR | P-value |
|---|---|---|---|---|---|
| Good functional outcome, defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days. | Primary | 42.2% (27/64) | 68.5% (50/73) | 26.31% | 0.003 |
| Mortality at 90 days | Secondary | 10.9% (7/64) | 12.3% (9/73) | 1.000 | |
| Substantial Reperfusion (eTICI 2b/3) | Secondary | 83.7% (41/49) | 87.0% (60/69) | 0.791 | |
| Symptomatic ICH | Adverse | 2.9% (2/69) | 0.0% (0/51) | 0.507 | |
| Parenchymal Hematoma Type 2 (PH-2) | Adverse | 3.9% (2/51) | 2.8% (2/72) | 1.000 |
Subgroup Analysis
In a multivariable analysis, after adjusting for covariates, acute stenting continued to be associated with superior outcomes (OR 2.41; 95% CI, 1.09 to 5.32; P=0.029).
Criticisms
- This was a nonrandomized analysis from a prospective registry, so treatment decisions were at the discretion of the physician, introducing potential for selection bias.
- There were baseline differences between the groups; notably, the stented group had lower rates of atrial fibrillation and shorter onset-to-treatment times, which could confound the results.
- Details on the specifics of antiplatelet therapy regimens were not available.
- The status of the carotid artery patency after the acute phase was not systematically followed up.
Funding
Medtronic.
Based on: STRATIS Tandem Lesion (Stroke, 2019)
Authors: Ashutosh P. Jadhav, MD, PhD; Osama O. Zaidat, ..., MD; Tudor G. Jovin
Citation: Stroke. 2019;50:428-433.
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