Emergent Carotid Stenting for Acute Anterior Circulation Ischemic Stroke With Tandem Lesions

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

Publisher: Ovid Technologies (Wolters Kluwer Health)

: 2026

Neurology

: e214528

: 106

: 2

: 0028-3878

: 1526-632X

DOI: https://doi.org/10.1212/WNL.0000000000214528

: https://doi.org/10.1212/wnl.0000000000214528

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.

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The authors report no targeted funding.
M. Romoli is supported by a research grant from the Italian Stroke Association (ISA-AII) and has received funding for educational activities from CLS Behring and Boehringer. A. H. Katsanos is supported by a career award from the Heart & Stroke Foundation Canada. T. Nguyen reports serving as an associate editor of Stroke; a speaker for Genentech and Kaneka; and a consultant for Medtronic. T. Nguyen has received AMA educational grants from Medtronic, Stryker, Balt, and MicroVention/Terumo unrelated to this study; and serves as Endovascular Section Editor for World Neurosurgery. All other authors report no disclosures relevant to this manuscript.