跟读练习: SVINutes: Approach to Tandem Occlusions - 通过视频学习英语口语
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Hello, I'm Dr. Hisham Salahuddin.
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In today's Sphinits, we will explore the management of tandem occlusions, a complex and evolving area in acute stroke management.
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Tandem occlusions involve severe stenosis or occlusion of an extracranial vessel,
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typically the cervical internal carotid artery accompanied by an intracranial occlusion.
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This dual occlusion presents unique challenges in both medical and neuroendovascular treatment.
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Tandem occlusions are often associated with a high clot burden, particularly if the extracranial lesion is occluded.
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Many questions remain about the optimal management of tandem occlusions as no randomized studies have specifically addressed this group.
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Data only exists from multi-center registries and meta-analysis.
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Key questions include the role of intravenous thrombolysis, endovascular approach to extra or intracranial recanalization first,
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the use of acute angioplasty or stenting, and post-procedural antiplatelet regimens.
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Clinical trials have shown that adding IV thrombolysis to mechanical thrombectomy is not non-inferior to MT alone.
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However, given the large clot burden and frequent post-procedural antiplatelet needs, some question its routine use in tandem occlusions.
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A pooled analysis of the Titan and Etis registries demonstrated improved recanalization
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and functional outcomes without an increase in symptomatic ICH with IV thrombolysis in this setting.
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A meta-analysis of over 1,800 patients across nine studies also supports its use.
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Administration of IV thrombolysis for tandem occlusions is safe and effective.
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Neuroendovascular treatment can involve an extracranial first or anterograde approach, addressing the proximal lesion first,
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or an intracranial first or retrograde approach, targeting the distal occlusion first.
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Endovascular approach is often influenced by occlusion etiology, degree of stenosis, and operator preference and experience.
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An intracranial first or retrograde approach may result in faster recanalization times
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and data from a German observational registry along with a meta-analysis by Zavellas
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and colleagues suggest that this could lead to improved clinical outcomes.
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While acute stenting for tandem occlusions requires post-procedural antithrombotics,
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The rates of symptomatic hemorrhage are comparable to those in patients who do not undergo stenting.
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Acute stenting has demonstrated better clinical outcomes than angioplasty alone in two large multi-center studies with over 600 patients each,
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as well as in a meta-analysis of nearly 6,400 patients.
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However, the effectiveness of stenting may be influenced by the underlying proximal etiology, whether due to carotid atherosclerosis or dissection.
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Following intervention, acute antiplatelet therapy is essential to prevent reocclusion.
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Approaches vary widely as revealed from a survey of 209 neurointerventionists with diverse training backgrounds.
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Some practitioners prefer dual antiplatelet therapy to mitigate immediate thrombotic risks, while others choose a single agent based on bleeding risk.
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The optimal antiplatelet protocol remains an area of active investigation.
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While we've made significant progress, important questions remain.
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Ongoing research including trials such as the PICASO, TITAN and Eastside Talk will help answer these questions and refine our treatment algorithms.
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In summary, tandem occlusion management is multifaceted.
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Advances in research continue to shape best practices, helping to optimize outcomes in this challenging patient population.
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Both IV thrombolysis and acute stenting appear to be safe and effective effective.
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Both anterograde or retrograde approaches are viable.
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Though an intracranial first approach may offer greater benefit, data is currently insufficient to support a specific antiplatelet regimen.
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Thank you for joining this discussion on tandem occlusions.
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