Commentary - Journal of Experimental Neurology (2021) Volume 2, Issue 1
Posterior Circulation Tandem Occlusions- Classification and Techniques: A Commentary
Shelly Sharma1*, Michael McAree1, Hekmat Zarzour2
1Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
2Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
- *Corresponding Author:
- Shelly Sharma
Received date: December 22, 2020; Accepted date: February 27, 2021
Citation: Sharma S, McAree M, Zarzour H. Posterior Circulation Tandem Occlusions- Classification and Techniques: A
Commentary. J Exp Neurol. 2021;2(1): 47-48.
Copyright: © 2021 Sharma S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
We want to congratulate the authors for this well-written review on posterior circulation tandem occlusions. Posterior circulation tandem occlusion is an area of neurosurgery that has not been heavily studied, particularly in regards to treatment modalities. These strokes occur more rarely than other forms of stroke and, frequently, conventional surgical intervention is no longer an option by the time patients present to the hospital. Fortunately, evolving technologies have made it possible for neurosurgeons to add mechanical thrombectomy in the posterior circulation to the armamentarium of posterior stroke treatment. They have successfully adapted their surgical skills for treating anterior circulation tandem occlusions to perform similar procedures in the posterior circulation.
Surgery of posterior circulation tandem occlusion is technical and challenging, but crucial; unfortunately, the outcome is dismal if the condition goes untreated. Multiple modalities exist for mechanical thrombectomy. Cohen et al. divide them into categories they define as “dirty road pathway” and “clean road pathway”. The dirty road pathway is more technically complicated and has an increased risk of complications. It can be done using either an antegrade or a retrograde approach. All the cases reviewed in this paper underwent mechanical thrombectomy in what Cohen et al. describes as “a dirty road pathway with a retrograde approach” .
As in any surgical procedure, it is essential to understand how supplementary steps may alter outcomes. Thus, the author needed to address the pros and cons of stenting for plaque management at the vertebral artery ostium of before versus after thrombectomy. In an antegrade approach, stent placement at the vertebral artery ostium is followed by basilar artery thrombectomy. While it is argued that this may stabilize the plaque, there is a reported increase in TTR of the posterior fossa and hemorrhage risk. In the retrograde approach, the basilar thrombectomy precedes the proximal vertebral artery stent-assisted angioplasty. This approach reportedly offers a decreased TTR and improved patient outcomes, but may increase the risk of vertebral to basilar re-embolization during stent placement. Providing the best possible care for each patient requires weighing the risks and benefits of each approach on an individual basis.
In the paper, three very distinct posterior circulation
tandem occlusions are defined: true tandem occlusion of the
vertebral and basilar artery, “J” occlusion,” and posterior
circulation pseudo-occlusion. Each case demonstrated
either acute basilar artery occlusion due to vertebral artery
stenosis or occlusion with thromboembolism. Despite
the technical complexity and increased risks, a dirty
road pathway with a retrograde approach was deemed
necessary in these cases. With the more challenging
procedure, a higher rate of complications was expected.
Though Weinberg et al. did not report any periprocedural
distal embolic occurrences, the mortality of 41.2%
parallels previous literature. Even when the vertebral
artery presented with stenosis or high-grade occlusion,
mechanical thrombectomy was shown to be feasible,
safe, and effective for the treatment of the basilar artery
occlusion. While the treatment modality for maintaining
patency of the vertebral artery differed, overall outcomes
were relatively similar. Thus, the author nicely addresses
the technical aspects of mechanical thrombectomy in such
challenging diseases, describing the different approaches
and treatment options to illustrate the safety and feasibility
of mechanical thrombectomy in posterior circulation
While the study is small and nonrandomized due to the disease’s rarity, the outcomes were consistent with published data. Only 17 cases of posterior circulation tandem occlusions were encountered during the five years covered in the study. Thesmall sample size makes generalizing the results difficult, especially when discussing postprocedural complications. The complications recorded by the authors included periprocedural intracranial hemorrhage (2 cases, 11.8%), periprocedural distal embolic (0 cases, 0%), periprocedural vessel dissection (1 case, 5.9%), periprocedural vessel perforation (1 case, 5.9%), and post-procedural symptomatic intracranial hemorrhage (1 case, 5.9%). With only one or two cases of the 17 having peri- or post-procedural complications, it is tempting to consider the surgeons’ treatment modalities unequivocally successful. However, it is unknown whether the rate of complications would remain low with a larger sample size.
Currently, there is no well-established optimal approach to the endovascular intervention of posterior circulation tandem occlusions. In our opinion, this paper offers an excellent blueprint for the future. It outlines very clearly the definitions for posterior circulation tandem occlusion, its various treatment modalities, and complications that may arise with each methodology. Most of all, it gives promise that posterior circulation tandem occlusions can be remedied. Future (and larger) randomized studies evaluating different treatment modalities and the risk and benefits of each l intervention will show which approach is the best when confronted with posterior circulation tandem occlusions. Until then, we will rely on such small cohorts’ papers which demonstrate the safety and effectiveness of mechanical thrombectomy following a posterior circulation tandem occlusion.
- Cohen JE, Leker RR, Gomori JM, Eichel R, Rajz
G, Moscovici S, et al. Emergent revascularization of
acute tandem vertebrobasilar occlusions: endovascular
approaches and technical considerations—confirming
the role of vertebral artery ostium stenosis as a cause of
vertebrobasilar stroke. Journal of Clinical Neuroscience.
2016 Dec 1;34:70-6.
- Weinberg JH, Sweid A, Sajja K, Abbas R, Asada A,
Kozak O, et al. Posterior circulation tandem occlusions:
Classification and techniques. Clinical Neurology and
Neurosurgery. 2020 Nov 1;198:106154.