Abstract
Background Tandem lesion strokes (TLS), defined by the coexistence of an intracranial large- or medium-vessel occlusion and a concomitant cervical internal carotid artery (ICA) stenosis or occlusion, represent a challenging subtype of acute ischemic stroke. Optimal endovascular management remains controversial, particularly regarding the role of emergent carotid artery stenting (eCAS) during mechanical thrombectomy.
Objective To compare the safety and efficacy of emergent carotid artery stenting versus mechanical thrombectomy alone in patients with anterior circulation tandem lesion strokes treated at a comprehensive stroke center.
Methods We conducted a retrospective observational cohort study of consecutive adults with anterior circulation TLS treated with endovascular therapy within 24 hours of symptom onset between January 2015 and July 2025. Patients were categorized into two groups according to treatment strategy: eCAS performed during thrombectomy or mechanical thrombectomy alone (MTa). Primary efficacy outcomes were ordinal shift in 90-day modified Rankin Scale (mRS), excellent outcome (mRS 0–1), and functional independence (mRS 0–2). Secondary efficacy outcome was successful recanalization (TICI ≥2b). Primary safety outcomes included symptomatic intracranial hemorrhage (sICH), in-hospital mortality, and 90-day mortality.
Results A total of 111 patients were included (mean age 71.2 ± 12.6 years; 68.5% male), of whom 74 (67%) underwent eCAS and 37 (33%) received MTa. Patients treated with eCAS achieved higher rates of successful recanalization (97.3% vs 78.4%; OR 13.26, 95% CI 2.13–82.49; p = .006) and excellent functional outcomes at 90 days (41.9% vs 12.5%; OR 6.80, 95% CI 1.35–34.20; p = .020). There were no significant differences between groups in rates of sICH, early neurological deterioration, or mortality. Ordinal logistic regression showed a non-significant trend toward better functional outcomes with eCAS.
Conclusions In this single-center experience, emergent eCAS during mechanical thrombectomy for TLS was associated with higher reperfusion rates and improved functional outcomes without increased hemorrhagic risk or mortality. These findings support eCAS as a feasible and safe strategy in selected patients and highlight the need for prospective randomized trials.
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
No funding was received to conduct this research.
Author Declarations
I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.
Yes
The details of the IRB/oversight body that provided approval or exemption for the research described are given below:
Ethics approval for this study was waived by the Bioethics Committee of Clínica La Sagrada Familia-ENERI on 1st July 2025
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Yes
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Data availability statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
