Emergent Carotid Stenting After Thrombectomy in Patients With Tandem Lesions

A 68-year-old diabetic woman presents to the emergency department 1 hour after right-sided hemiplegia and global aphasia. National Institutes of Health Stroke Scale score is 21; Alberta Stroke Program Early CT score (ASEPCTS) on computed tomographic scan is 8; and computed tomographic angiography shows severe left internal carotid artery stenosis and proximal left M1 middle cerebral artery occlusion (tandem lesion). She is treated with intravenous tPA (tissue-type plasminogen activator) and is being considered for endovascular intervention.Would you consider a left internal carotid artery stenting immediately after successful thrombectomy (thrombolysis in cerebral infarction [TICI]-3)? If so, when do you start dual-antiplatelet therapy?Emergent carotid stenting after thrombectomy in patients with tandem lesions. Daniel BehmeI would always go for stenting of the internal carotid artery (ICA) stenosis because the clot in the middle cerebral artery was likely caused by the stenosis. Therefore, acute stenting in combination with thrombectomy allows for treatment of the symptomatic middle cerebral artery occlusion and the suspected cause of the stroke, the severe ICA stenosis, simultaneously. More importantly, I would never refuse to provide endovascular therapy (EVT) because of an underlying tandem lesion. The data of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) have shown that patients having tandem occlusions benefit from EVT.1 This was also true for the other randomized trials, which are summarized in the HERMES meta-analysis (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials).2 Immediate stenting is thereby justified for 2 reasons. First, the ICA stenosis is obviously symptomatic and therefore should be considered for stenting or surgical treatment according to the current recommendations anyway.3 Second, it is much easier to perform intracranial thrombectomy if one can place a large guiding catheter or a femoral long sheath distally in the ICA …