ABSTRACT NUMBER: ESOC2026A2365 COMPLETE REPERFUSION AFTER TANDEM OCCLUSION – A CASE REPORT

Abstract Background and aims Tandem lesions—intracranial large-vessel occlusion with severe ipsilateral extracranial internal carotid artery (ICA) stenosis—is a complex clinical scenario. We report a case of a 55-year-old male with ischemic stroke due to right ICA and M1 occlusion, highlighting decision-making dilemmas, technical aspects and clinical considerations regarding perioperative tirofiban infusion. Methods case report Results The patient presented with acute-onset left face drooping, hemiplegia, hemisensory loss and hemineglect (NIHSS 12). He was air-transferred to a comprehensive stroke center. Neuroimaging showed a small ischemic lesion in the right internal capsule (ASPECTS 9) and right ICA and M1 occlusions. He received 25mg of tenecteplase and was transferred to the neurointerventional unit. The following procedures were performed in sequential order: ICA balloon angioplasty, MT of right M1 and retrograde right ICA stenting. The patient received bolus IV tirofiban (12 μg/kg) followed by an 18-hour infusion (0.1 μg/kg/minute); dual antiplatelet therapy was then initiated. Discharge NIHSS was 2 and mRS was 1. Conclusions This case underscores the complexity of tandem occlusions in ischemic stroke. Intravenous thrombolysis with tenecteplase is safe and effective independent of subsequent thrombectomy. ΜΤ followed by retrograde carotid artery stenting is the recommended approach. The periprocedural antithrombotic regimen in tandem occlusions is a matter of ongoing debate; perioperative tirofiban can be used as adjunct antithrombotic therapy during emergent carotid artery stenting with a favorable clinical outcome; further research should define predictors of bleeding risk to optimize patient selection and protocol individualization. Conflict of interest Konstantinos Ntoskas: nothing to disclose, Christos Toilos: nothing to disclose, Ioannis Dedes: nothing to disclose, Ifigeneia Balatsouka: nothing to disclose, Ioanna Spanou: nothing to disclose, Vassiliki Deligianni: nothing to disclose, Olga Sideri: nothing to disclose, Antonios Tsagkaropoulos: nothing to disclose, Evangelos Kouremenos: nothing to disclose.