Technical note Emergency endovascular revascularization of tandem occlusions: Internal carotid artery dissection and intracranial large artery embolism José E. Cohen a,b,⇑ , Ronen R. Leker c , Roni Eichel c , Moshe Gomori b , Eyal Itshayek a a Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel b Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel c Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel article info Article history: Received 26 November 2015 Accepted 5 December 2015 Available online xxxx Keywords: Closed-cell stent Internal carotid artery dissection Ischemic stroke Stent-assisted revascularization Stent thrombectomy abstract Internal carotid artery dissection (ICAD) with concomitant occlusive intracranial large artery emboli is an infrequent cause of acute stroke, with poor response to intravenous thrombolysis. Reports on the man- agement of this entity are limited. We present our recent experience in the endovascular management of occlusive ICAD and major intracranial occlusion. Consecutive anterior circulation acute stroke patients meeting Medical Center criteria for endovascular management of ICAD from June 2011 to June 2015 were included. Clinical, imaging, and procedure data were collected retrospectively under Institutional Review Board approval. The endovascular procedure for carotid artery revascularization and intracranial stent thrombectomy is described. Six patients met inclusion criteria (National Institutes of Health Stroke Scale score 12–24, time from symptom onset 2–8 hours). Revascularization of the extracranial carotid dissection and stent thrombectomy were achieved in 5/6 patients, resulting in complete recanalization (Thrombolysis in Myocardial Infarction flow grade 3 in a mean 2.7 hours), and modified Rankin Scale score 0–2 at 90 day follow-up. In one patient, attempts to microcatheterize the true arterial lumen failed and thrombectomy was therefore not feasible. No arterial dissection, arterial rupture or accidental stent detachment occurred, and there was no intracerebral hemorrhage or hemorrhagic transformation. Our preliminary data on this selected subgroup of patients suggest the presented approach is safe, feasible in a significant proportion of patients, and efficacious in achieving arterial recanalization and improving patient outcome. Crossing the dissected segment remains the most important limiting factor in achieving successful ICA recanalization. Further evaluation in larger series is warranted. Ó 2015 Elsevier Ltd. All rights reserved. 1. Introduction Internal carotid artery dissection (ICAD) causing occlusion or near occlusion with concomitant intracranial large artery emboli is an infrequent but important cause of severe and life- threatening acute stroke [1–3]. In this situation, as in tandem occlusions of atherosclerotic origin, intravenous thrombolysis has had very limited success. Emergency and aggressive endovascular intervention is required, but these procedures are challenging due to the combination of difficult access and the need to revascu- larize long and complex extracranial carotid lesions that make intracranial mechanical thrombectomy more difficult and time consuming [4–6]. In this article we present our recent experience in the endovas- cular management of a series of patients with occlusive ICAD and major intracranial occlusions, with a focus on the technical aspects of the intervention. 2. Material and methods 2.1. Patients Between June 2011 and June 2015, all consecutive anterior cir- culation acute stroke patients with a National Institutes of Health Stroke Scale (NIHSS) score P10 presenting within 6 hours from symptom onset were triaged on admission for potential endovas- cular mechanical thrombectomy. Endovascular treatment was also the first choice in patients with a finding of major intracranial occlusion on admission CT angiography (CTA). In addition, endovascular management was considered for patients presenting with a NIHSS score <10 and with clinically fluctuating symptoms or deterioration after admission, as well as for those last seen well beyond the 6 hour threshold who had a mismatch between http://dx.doi.org/10.1016/j.jocn.2015.12.003 0967-5868/Ó 2015 Elsevier Ltd. All rights reserved. ⇑ Corresponding author. Tel.: +972 2 677 7092; fax: +972 2 641 6281. E-mail address: jcohenns@yahoo.com (J.E. Cohen). Journal of Clinical Neuroscience xxx (2016) xxx–xxx Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Please cite this article in press as: Cohen JE et al. Emergency endovascular revascularization of tandem occlusions: Internal carotid artery dissection and intracranial large artery embolism. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.12.003