Robert W. Regenhardt, MD, PhD
Jadhav AP, Zaidat OO, Liebeskind DS, Yavagal DR, Haussen DC, Hellinger FR, et al. Emergent Management of Tandem Lesions in Acute Ischemic Stroke: Analysis of the STRATIS Registry. Stroke. 2018;50:428–433.
With the 2015 trials irrefutably showing the superiority of endovascular thrombectomy (ET) over intravenous tPA alone for the treatment of stroke secondary to large vessel occlusion (LVO), and the 2018 trials showing it may be effective for up to 24 hours from symptom onset, current research efforts focus on expanding the number of patients who may be eligible for this highly effective treatment (e.g., larger core, more distal occlusions) and optimizing protocols for more complex cases. The latter is exemplified by questions that remain about the best approach to treating tandem lesions, which involve both the cervical internal carotid artery (ICA) and an intracranial artery. The most common etiology is cervical ICA atherosclerosis, but tandem lesions can also result from cervical ICA dissection.
Perhaps the biggest conundrum in the management of tandem lesions is whether or not to stent the cervical ICA in the acute setting. Given the risk of dual antiplatelet therapy, especially in patients who received tPA and have larger cores, some interventionalists choose to defer in the acute setting and offer stenting versus endarterectomy later. If stenting is offered in the acute setting, it is unclear whether cervical ICA stenting should be done before or after intracranial ET. Furthermore, the role of angioplasty and the optimum antithrombotic regimen have yet to be determined. There is limited data available to help guide these decisions. While many of the ET trials included patients with tandem lesions, the management was highly variable. Tandem lesions were present in 32% of MR CLEAN, 18% of REVASCAT, and 17% of ESCAPE, while they were excluded from SWIFT PRIME and EXTEND IA. An analysis of the 30 patients with tandem lesions that were treated with ET in ESCAPE showed 17 underwent cervical ICA stenting, 10 before and 7 after intracranial ET. Of the 13 for which stenting was deferred in the acute setting, only 4 underwent ICA revascularization later.