STRATIS Tandem Lesion
(2019)Objective
To assess outcomes in patients with tandem occlusions undergoing mechanical thrombectomy, comparing those treated with acute carotid stenting vs. no stenting.
Study Summary
• No increase in symptomatic ICH or mortality was observed.
• IV tPA was used in the majority of both groups, and thrombolysis was not associated with increased bleeding in stented patients.
Intervention
Multicenter, prospective, nonrandomized STRATIS registry evaluating patients undergoing thrombectomy with the Solitaire device for anterior circulation stroke. Management of tandem lesions (intracranial LVO + extracranial ICA stenosis) was at physician discretion: acute stenting vs. no stenting (with or without angioplasty).
Inclusion Criteria
Adults with anterior circulation large vessel occlusion, NIHSS ≥8, mRS 0–1, treated within 8 hours of onset. Tandem lesions defined as concurrent cervical ICA stenosis/occlusion and intracranial LVO.
Study Design
Arms: Acute Carotid Stenting vs. No Stenting
Patients per Arm: Stenting: 80; No stenting: 67 (43 of whom had angioplasty alone)
Outcome
• Symptomatic ICH: 2.9% (stenting) vs. 0% (no stenting); not statistically significant
• Mortality: 12.3% (stenting) vs. 10.9% (no stenting); no significant difference
• Subgroup analysis: Stenting remained an independent predictor of good outcomes (adjusted OR 2.41; 95% CI 1.09–5.32; P=0.029)
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.
Study Design
- Study Type
- Prospective, multicenter, nonrandomized, observational registry.
- Randomization
- No
- Blinding
- Not applicable (observational registry).
- Sample Size
- 147
- Follow-up
- 90 days.
- Centers
- 55
- Countries
- United States
Primary Outcome
Definition: Good functional outcome, defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days.
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| 42.2% (27/64) | 68.5% (50/73) | - | 0.003 |
Limitations & 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.
Citation
Stroke. 2019;50:428-433.