Emergent Carotid Stenting for Acute Anterior Circulation Ischemic Stroke With Tandem Lesions: The Multicenter CERES-TANDEM Study.

Background And Objectives The management of anterior circulation tandem lesion stroke remains controversial, given its under-representation in randomized thrombectomy trials and uncertainty regarding optimal extracranial carotid intervention. We aimed to determine whether emergent carotid stenting (eCAS) during endovascular thrombectomy (EVT) for anterior circulation tandem lesions improves 90-day functional outcomes compared with a no-stenting strategy.Methods We conducted an international multicenter longitudinal retrospective cohort study (CERES-TANDEM, NCT06965036) of consecutive adults treated at 49 comprehensive stroke centers in Europe, North America, and Singapore for anterior circulation acute ischemic stroke due to tandem lesions from January 1, 2018, to December 31, 2024. Exclusion criteria were primary hemorrhagic stroke, absence of intracranial occlusion, presentation >24 hours from symptom onset, and age younger than 18 years. We compared 90-day modified Rankin Scale (mRS) scores between participants receiving eCAS and those receiving no stenting during EVT. The primary estimand was mRS shift, analyzed by stabilized inverse probability of treatment weighting (IPTW)-weighted ordinal regression. Additional estimands were direct-effect estimand adjusting for successful recanalization (defined as Thrombolysis in Cerebral Infarction grade 2b or higher) and symptomatic intracranial hemorrhage (sICH) (estimand 2) and stratum estimand restricting to never-crossers (estimand 3).Results Of 4,053 patients (mean age 70 years, 65.5% female), 2,522 underwent eCAS and 1,531 received no stenting. After IPTW, eCAS was associated with an improved 90-day functional outcome (common odds ratio (OR) 1.31; 95% CI 1.17-1.47;p < 0.001) and higher odds of mRS score 0-1 (OR 1.27; 95% CI 1.08-1.50; p = 0.005) and mRS score 0-2 (OR 1.30; 95% CI 1.13-1.51; p < 0.001), without a significant increase in sICH (OR 1.21; 95% CI 0.93-1.56; p = 0.15). Findings were consistent in direct-effect (common OR 1.17; 95% CI 1.04-1.31; p = 0.008) and stratum (common OR 1.37; 95% CI 1.21-1.55; p < 0.001) estimands. There was no interaction for intracranial occlusion site, IV thrombolysis, sedation technique, EVT approach, or access site. Sensitivity analysis including recanalization in IPTW-weighted estimand 1 framework confirmed the association of eCAS with improved 90-day functional outcomes (common OR 1.14, 95% CI1.02-1.27, p = 0.008).Discussion In this large real-world cohort, eCAS during EVT for anterior circulation tandem lesions was associated with superior 90-day functional recovery without increased hemorrhagic risk. These findings support consideration of eCAS in clinical practice and warrant confirmation in randomized trials.Trial Registration Information Registered in clinicaltrials.gov, NCT06965036.Classification Of Evidence This study provides Class II evidence that in patients with stroke due to anterior circulation tandem lesions, eCAS during EVT improves 90-day functional outcomes compared with EVT alone.

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Open Access CRIS of the University of Bern
Published
2026-01-05
DOI
https://doi.org/10.48620/93579
Primary Topic
Acute Ischemic Stroke Management
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article
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article

Emergent Carotid Stenting for Acute Anterior Circulation Ischemic Stroke With Tandem Lesions: The Multicenter CERES-TANDEM Study.

Danilo Toni, Jessica Jesser, Paolo Candelaresi, Johannes Kaesmacher et al.
Open Access CRIS of the University of Bern
Acute Ischemic Stroke Management
article

Emergent Carotid Stenting for Acute Anterior Circulation Ischemic Stroke With Tandem Lesions: The Multicenter CERES-TANDEM Study.

Danilo Toni, Jessica Jesser, Paolo Candelaresi, Johannes Kaesmacher, Uta Hanning, Francesco Toraldo, Christian H. Nolte, Sebastiano Giacomozzi, Michele Romoli, Mohamad K. Abdalkader, Michael Abraham, Antonio Toscano, Shail Thanki, Manuel Requena, Volker Maus, S Greisenegger, Federica Nicoletta Sepe, Karolin Schulte, Valentina Tudisco, Ettore Nicolini, Aristeidis H. Katsanos, Espen Saxhaug Kristoffersen, Francesca Rosafio, Anna Gardin, Thanh N. Nguyen, Vinay Jaikumar, Lee Rosterman, Ludovica Ferraù, Kemal Alpay, Barbara Casolla, Antioco Sanna, Vincenzo Andreone, Maiken Nordahl Selseth, Aikaterini Anastasiou, Stefano Caproni, Tilman Reiff, Marcello Naccarato, Stefania Maffei, Guillaume Thévoz, Răzvan Alexandru Radu, Angelo Taglialatela, Fabrizio Giammello, Mirjam R. Heldner, Roland Schwab, Ahmad Abu Qdais, Mariarosaria Valente, Puetz Volker, Alessandro Pezzini, Alejandro Tomasello, Luca Scarcia, Rossana Tassi, Vincent Costalat, Marios Psychogios, Adnan Mujanovic, Giovanni Merlino, Lucio D'Anna, João Pedro Marto, Abdulrahman Abu Amara, Mafalda Delgado Soares, Elena Zapata-Arriaza, Andrea Zini, João André Sousa, Francesco Diana, Francesco Arba, Alexandra Aust, Joseph Domenico Gabrieli, Ludovica Migliaccio, Emanuele Spina, P. O. Michel, Christine Hawkes, Maurizio Paciaroni, Costanza Maria Rapillo, Marieta Peycheva, Elvis Lafe, Andrea M Alexandre, Peter Arthur Ringleb, Markus Möhlenbruch, Maria Ruggiero, Martin Köhrmann, Andre Monteiro, Diana Aguiar De Sousa, Sami Al Kasab, Leonard Yeo, Jordi Kühne Escolà, Piers Klein, Adnan H Siddiqui, Manuel Medina-Rodriguez, Luigi Bellini, Simone Ferretti, Valerio Da Ros, Daniel Kaiser, Marco Longoni, Guido Bigliardi, Simona Lattanzi, Carlos A Molina
article en

Abstract

Background And Objectives The management of anterior circulation tandem lesion stroke remains controversial, given its under-representation in randomized thrombectomy trials and uncertainty regarding optimal extracranial carotid intervention. We aimed to determine whether emergent carotid stenting (eCAS) during endovascular thrombectomy (EVT) for anterior circulation tandem lesions improves 90-day functional outcomes compared with a no-stenting strategy.Methods We conducted an international multicenter longitudinal retrospective cohort study (CERES-TANDEM, NCT06965036) of consecutive adults treated at 49 comprehensive stroke centers in Europe, North America, and Singapore for anterior circulation acute ischemic stroke due to tandem lesions from January 1, 2018, to December 31, 2024. Exclusion criteria were primary hemorrhagic stroke, absence of intracranial occlusion, presentation >24 hours from symptom onset, and age younger than 18 years. We compared 90-day modified Rankin Scale (mRS) scores between participants receiving eCAS and those receiving no stenting during EVT. The primary estimand was mRS shift, analyzed by stabilized inverse probability of treatment weighting (IPTW)-weighted ordinal regression. Additional estimands were direct-effect estimand adjusting for successful recanalization (defined as Thrombolysis in Cerebral Infarction grade 2b or higher) and symptomatic intracranial hemorrhage (sICH) (estimand 2) and stratum estimand restricting to never-crossers (estimand 3).Results Of 4,053 patients (mean age 70 years, 65.5% female), 2,522 underwent eCAS and 1,531 received no stenting. After IPTW, eCAS was associated with an improved 90-day functional outcome (common odds ratio (OR) 1.31; 95% CI 1.17-1.47;p < 0.001) and higher odds of mRS score 0-1 (OR 1.27; 95% CI 1.08-1.50; p = 0.005) and mRS score 0-2 (OR 1.30; 95% CI 1.13-1.51; p < 0.001), without a significant increase in sICH (OR 1.21; 95% CI 0.93-1.56; p = 0.15). Findings were consistent in direct-effect (common OR 1.17; 95% CI 1.04-1.31; p = 0.008) and stratum (common OR 1.37; 95% CI 1.21-1.55; p < 0.001) estimands. There was no interaction for intracranial occlusion site, IV thrombolysis, sedation technique, EVT approach, or access site. Sensitivity analysis including recanalization in IPTW-weighted estimand 1 framework confirmed the association of eCAS with improved 90-day functional outcomes (common OR 1.14, 95% CI1.02-1.27, p = 0.008).Discussion In this large real-world cohort, eCAS during EVT for anterior circulation tandem lesions was associated with superior 90-day functional recovery without increased hemorrhagic risk. These findings support consideration of eCAS in clinical practice and warrant confirmation in randomized trials.Trial Registration Information Registered in clinicaltrials.gov, NCT06965036.Classification Of Evidence This study provides Class II evidence that in patients with stroke due to anterior circulation tandem lesions, eCAS during EVT improves 90-day functional outcomes compared with EVT alone.

Open Access CRIS of the University of Bern
Openalex Percentile: Top 96%
Acute Ischemic Stroke Management
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