Endovascular Management of Tandem Occlusions in Acute Ischemic Stroke

Tandem occlusions, characterised by a concurrent intracranial large-vessel blockage and a stenosis or occlusion of the cervical internal carotid artery, present a formidable challenge in acute ischaemic stroke care. Rapid restoration of cerebral perfusion is critical to limit neuronal injury, yet the optimal strategy for addressing both the intracranial thrombus and the proximal carotid lesion remains debated. Endovascular approaches typically combine mechanical thrombectomy to retrieve the clot in the middle or anterior cerebral arteries with parallel management of the cervical carotid lesion, often via angioplasty and stent placement. Key considerations include the timing and sequence of intracranial versus extracranial treatment, choice of antithrombotic regimen to minimise haemorrhagic risk, and technical refinements to preserve collateral flow. Advances in stent-retriever design, real-time imaging guidance and periprocedural pharmacology have underpinned improved recanalisation rates. Nonetheless, heterogeneity in patient anatomy, stroke aetiology—atherosclerotic plaque versus dissection—and institutional protocols continues to influence outcomes. A growing body of observational and registry data has shed light on factors predicting functional independence, such as time to reperfusion, residual stenosis, and haemorrhagic complications, while prospective trials are underway to standardise approaches. The global imperative is to refine algorithms that balance rapid intracranial recanalisation with safe and durable treatment of the cervical lesion, thereby maximising neurological recovery and minimising procedural risks.

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Endovascular Management of Tandem Occlusions in Acute Ischemic Stroke publication trend

The graph below shows the total number of articles in endovascular management of tandem occlusions in acute ischemic stroke across all publications each year (not limited to Nature Index journals).

Technical terms

Tandem occlusion: Simultaneous blockage of a cervical internal carotid artery lesion and an intracranial large-vessel thrombus.

Mechanical thrombectomy: Endovascular removal of an arterial clot using stent-retriever or aspiration devices to restore blood flow.

Carotid artery stenting (CAS): Deployment of a self-expanding stent in the cervical internal carotid artery to re-establish patency.

Modified Thrombolysis in Cerebral Infarction (mTICI) score: Angiographic grading system (0–3) assessing the degree of reperfusion achieved in treated vessels.

Modified Rankin Scale (mRS): Clinical scale (0–6) measuring global disability and functional independence after stroke.

References

1. Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions. JAMA Network Open (2023).
2. Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions. American Journal of Neuroradiology (2020).
3. Endovascular treatment of acute ischemic stroke due to tandem lesions of the anterior cerebral circulation: a multicentric Italian observational study. La radiologia medica (2021).
4. Carotid Stenting and Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Tandem Occlusions: Antithrombotic Treatment and Functional Outcome. American Journal of Neuroradiology (2020).