Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions

Abstract

Approximately 15% of patients undergoing endovascular thrombectomy for anterior circulation acute ischemic stroke have a tandem lesion, defined as a severe stenosis or occlusion of the cervical internal carotid artery ipsilateral to its intracranial occlusion. Patients with tandem lesions have worse outcomes than patients with isolated intracranial occlusions, but the optimal management of their carotid lesions during endovascular thrombectomy remains controversial. The main options commonly used in current practice include acute stent placement in the carotid lesion versus thrombectomy alone without definitive revascularization of the carotid artery. While treatment decisions for these patients are often complex and strategies vary according to clinical, anatomic, and technical considerations, only results from randomized trials comparing these approaches are likely to strengthen current recommendations and optimize patient care.

Considerations for Antiplatelet Management of Carotid Stenting in the Setting of Mechanical Thrombectomy: A Delphi Consensus Statement

“…disadvantages of carotid stent placement in the setting of EVT, [1][2][3] and the need for dual-antiplatelet therapy is often cited as an argument to forego emergent stent placement. Some authors even argue that emergent carotid endarterectomy might be a better alternative because it does not require dual antiplatelet therapy.…”

Mechanical thrombectomy in acute ischemic stroke with tandem occlusions: impact of extracranial carotid lesion etiology on endovascular management and outcome

“…Some authors considered stenting in TOs to be potentially hazardous, 25 while others tend to perform carotid artery stenting immediately after successful thrombectomy. 26 In a study recently reported by our group, we found that emergency stenting is safer in defined circumstances, including intraprocedural heparin avoidance, baseline ASPECTS > 8, and a straightforward MT with a first-pass complete recanalization. 27 In the present study, we confirmed the safety and efficacy of emergency stenting in TOs irrespective of ECL etiology, without differences in terms of sICH risk between the two groups.…”

Comparative study on treatment of acute cerebral infarction between mechanical thrombectomy by micro catheter and thrombectomy by Solitaire AB stent

“…Our hospital summed up the following points for attention in the course of treatment [1] . The diameter of the vascular matching stent should be selected, because there are many bends of the internal carotid artery, so using Navien guide tube can reduce the walking distance of stent combined with thrombus, reduce the risk of thrombus detachment and improve the efficiency of vascular recanalization [2] .…”

“…There are many treatment methods for vascular recanalization, including intravenous thrombolysis, arterial thrombolysis, and mechanical thrombectomy, but the clinical outcome of intravenous thrombolysis and arterial thrombolysis is not good. [1,2] In recent years, intra-arterial mechanical therapy has gradually sprung up, such as destroying the thrombus of the occlusive segment or causing the embolus to deform and rupture through the arterial approach with the help of interventional equipment (guidewire, catheter, stent, etc). If necessary, interventional equipment can be used to remove the thrombus from the intracranial occlusive segment to restore and recanalize the occluded intracranial vessels.…”

“…Acute cerebral artery occlusion is a common disease with high morbidity and mortality, and vascular recanalization after occlusion is a prerequisite for a good clinical outcome. There are many treatment methods for vascular recanalization, including intravenous thrombolysis, arterial thrombolysis, and mechanical thrombectomy, but the clinical outcome of intravenous thrombolysis and arterial thrombolysis is not good [1,2] …”