Endovascular treatment of Tandem occlusion in acute ischemic stroke: a monocentric study.

Tandem occlusion (TO) is a severe form of acute ischemic stroke (AIS), involving simultaneous blockages in the cervical internal carotid artery (ICA) and a distal intracranial artery, typically the middle cerebral artery (MCA). This dual-level obstruction poses significant challenges, requiring timely and complex interventions to restore blood flow and reduce brain damage. The monocentric study under review investigates the outcomes of endovascular treatment (EVT) for TO, offering valuable insights into its effectiveness, safety, and technical strategies. The study was conducted in a single stroke center and included patients diagnosed with TO-related AIS confirmed via imaging. All patients were treated within 24 hours of symptom onset, provided imaging showed salvageable brain tissue. The standardized treatment protocol involved addressing the intracranial occlusion through mechanical thrombectomy (MT) with stent retrievers or aspiration devices, while the cervical ICA lesion was treated using angioplasty, stenting, or a combination of both, depending on the severity of the blockage. Eligible patients received intravenous thrombolysis (IVT) before EVT. Decisions regarding stenting versus angioplasty were individualized based on the lesion's characteristics and patient-specific factors. The study aimed to assess key outcomes, including the rate of successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b or higher), time to reperfusion, safety outcomes such as hemorrhagic complications or in-stent thrombosis, and functional recovery at 90 days, measured using the modified Rankin Scale (mRS). Results demonstrated that EVT achieved high rates of successful reperfusion, with most patients reaching mTICI scores of 2b or 3, reflecting substantial blood flow restoration. Functional outcomes were encouraging, with a high number of patients achieving mRS scores of 0–2 at 90 days, indicating functional independence despite the severity of their condition. Procedural times were consistent with those reported in other studies, highlighting the feasibility of managing TO within an acute setting. Safety outcomes were also favorable. Rates of hemorrhagic complications, including symptomatic intracranial hemorrhage (sICH), were comparable to or better than those observed in broader EVT studies. Risks associated with in-stent thrombosis were minimized through careful procedural planning and the use of dual antiplatelet therapy in cases where stenting was performed. These results suggest that EVT can be a safe and effective option for patients with TO-related AIS, even in this challenging subset of stroke cases. One of the study’s notable contributions was its focus on managing the cervical ICA lesion. While some lesions were treated effectively with angioplasty alone, stenting was required for high-grade stenosis or complete occlusions to ensure durable reperfusion. However, stenting carried additional risks, such as distal embolization or thrombosis, necessitating precise procedural decisions and patient-specific management strategies. The study highlights the importance of individualized approaches and operator expertise in achieving optimal outcomes. The monocentric nature of the study allowed for consistent protocols and follow-up, ensuring robust internal validity. However, this also represents a limitation, as the findings may not be fully generalizable to other centers with varying levels of experience or resources. Larger multicenter studies are needed to confirm these results and refine treatment strategies further. In conclusion, this study reinforces the viability of EVT for treating tandem occlusion in AIS. It demonstrates high rates of reperfusion, encouraging functional outcomes, and manageable safety risks. The findings underscore the importance of addressing both extracranial and intracranial blockages and highlight the role of tailored approaches in improving outcomes for this complex and high-risk patient population. EVT is a promising option for TO, offering significant benefits even in the face of its inherent challenges.