Elena Zapata-Arriaza, MD

Feil K, Herzberg M, Dorn F, Tiedt S, Küpper C, Thunstedt DC, Papanagiotou P, Meyer L, Kastrup A, Dimitriadis K; for the GSR investigators. Tandem Lesions in Anterior Circulation Stroke: Analysis of the German Stroke Registry-Endovascular Treatment. Stroke. 2021 ;52:1265-1275.

Technical management of tandem lesions still raises many questions. With the aim of investigating the safety and efficacy of different technical strategies in tandem lesions, the authors analyzed data from the German Stroke Registry—Endovascular Treatment between June 2015 and December 2019. The registry is an academic, independent, prospective, multicenter, observational registry study with 25 participating stroke centers from all over Germany enrolling consecutive mechanical thrombectomy patients.

Among 6635 analyzed patients, 874 (13.2%) presented with tandem lesions. Of these, 607 (69.5%) underwent acute treatment of the extracranial ICA. Acute treatment of the extracranial ICA lesion led to a higher probability of successful reperfusion (odds ratio, 40.63) compared with patients who did not undergo acute treatment of the extracranial ICA lesion and was associated with good clinical outcome (39.5% versus 29.3%, P<0.001) and a lower rate of mortality (17.1% versus 27.1%, P<0.001) at 3 months. Further significant predictors of successful reperfusion were age and intravenous thrombolysis. Intracranial-first approach compared with extracranial-first approach resulted in a shorter time to flow restoration (53.5 versus 72.0 minutes, P<0.001) and a higher nonsignificant probability of good outcome (45.8% versus 33.0%, P=0.24) without differences in periprocedural complications.

From this article, we can obtain relevant clues about the path to choose in patients with tandem lesions. First, whenever technically possible, try the intracranial approach first. This approach helps to achieve a correct optimal intracranial recanalization (TICI 2b-3) 20 minutes faster, which leads to an improvement in the functional status of the patient at 3 months. This should be the objective in tandem lesions, in light of the results of this study in which the complications associated with the procedure are similar in both approaches (intracranial vs extracranial first). And finally, the treatment of extracranial lesions in the acute phase has a triple impact on the benefit of the endovascular procedure: It increases the probability of successful reperfusion, it is associated with better functional outcomes, and it decreases the mortality rate. These results, although coming from a registry that requires confirmation in future clinical trials, establishes the bases to determine the fundamental obstacle to be solved in tandem lesions: It is essential to solve the intracranial as well as the extracranial occlusion. Improving the extracranial antegrade passage will help improve intracranial perfusion, reinforcing the benefit of intracranial mechanical thrombectomy. The most appropriate antiplatelet management that minimizes bleeding complications, as well as the need or not of a stent associated with angioplasty, remains to be established.