Perform a retrospective review of large vessel occlusion (LVO) in acute ischemic stroke (AIS) cases with tandem carotid lesions at a single center academic comprehensive stroke.

Among 220 LVO AIS patients who presented within 24 hours from last known well time (LKN) to our institution from May 2023 to June 30, 2024, we identified 36 (16.4%) patients with LVO and tandem carotid lesion. Data was collected on demographics, LKN, neuroimaging results, National Institute of Health Stroke Scale (NIHSS), thrombolysis time, and MT results.

Among 36 patients with LVO and tandem lesions, the mean age was 69.7 years (range, 40.0 to 95.0) and 15 (41.7%) were female. The mean NIHSS was 13.8 (range 3 to 23). The mean time from LKN to CTA was 7.6 hours (range, 0.4 to 20.6). The location of LVO was as follows: 23 (64.9%) M1, 9 (25.0%) M2, and 4 (11.1%) ICAT.  Among the tandem lesions, 30 (83.3%) were carotid occlusions and 6 (16.6%) were carotid stenoses. Fourteen (38.9%) received thrombolysis at a mean time from LKN 2.0 hours (range, 1.0 to 3.1).  Among 14 (38.9%) patients who underwent MT, 11 (78.6%) had successful recanalization. Among 22 patients excluded MT, proximal carotid occlusion was documented as the reason in 12 (54.5%). Patients with tandem carotid stenosis did not significantly differ from patients with tandem carotid occlusion in terms of age, sex, NIHSS, and time from LKN, but did have a higher rate of MT (83.3% vs 30.0%, p 0.014).

In LVO and tandem lesions, proximal carotid occlusion underwent MT at a lower rate than carotid stenosis. Further study warranted to optimize treatment in LVO patients with tandem carotid lesions.