Management of acute tandem occlusions: Stent-retriever thrombectomy with emergency stenting or angioplasty

A tandem occlusion is an uncommon presentation of acute stroke that involves an occlusion of the extracranial internal carotid artery (EICA) and concomitant occlusion of either the intracranial ICA and/or middle cerebral artery (MCA). 1,2 The underlying pathophysiology involves either atherosclerotic disease in older patients, or a dissection of the proximal vasculature in younger patients, leading to complete occlusion and an embolus causing a distal tandem occlusion.2, Due to the large clot burden and slow distal flow, systemic intravenous thrombolysis (IVT) alone often yields poor recanalization for acute tandem occlusion with recanalization rates ranging from 4.4 to 12.5%.4,5 Although endovascular treatment has achieved high recanalization rates and favourable outcomes in patients with anterior large vessel occlusion including those with tandem occlusions, the proportion of patients with a good clinical outcome following acute anterior tandem occlusion is only approximately 25%.6–8 Recently, several case series have reported that emergency extracranial carotid artery stenting followed by intracranial stent-retriever thrombectomy (SRT) was effective and had an acceptable safety profile in the treatment of acute anterior tandem occlusions.9–11 However, a major concern of this procedure is that dual-antiplatelet loading following acute carotid artery stenting may potentially increase the risk of post-interventional symptomatic intracerebral haemorrhage (SICH) in a freshly re-perfused ischemic tissue, especially following IVT.11 To our knowledge, in the setting of acute tandem occlusions, few studies have compared outcomes following intracranial SRT with emergency EICA stenting or angioplasty alone. Therefore, the aim of this prospective study was to investigate the impact of SRT with EICA stenting or angioplasty alone on neurological outcomes in patients with acute ischemic stroke due to tandem occlusions.