Objective:

To describe procedural strategies and clinical outcomes in patients with anterior circulation tandem occlusions treated at a comprehensive stroke center.

Background:

Tandem occlusions of the extracranial internal carotid artery (ICA) and intracranial large vessel occlusion (LVO) are complex and underrepresented in clinical trials, with limited real-world data, especially in underserved populations.

Design/Methods:

Patients with tandem occlusions were identified from a prospectively maintained LVO database between January 2022 and September 2024. Data collected included demographics, baseline NIHSS, imaging findings (occlusion site, ICA stenosis), and procedural details (thrombectomy approach, carotid stenting, time metrics, complications). The primary outcome was 90-day modified Rankin Scale (mRS); secondary outcomes included discharge disposition and in-hospital mortality.

Results:

Nine patients (mean age 71.4 years, 67% male, predominantly Latino) were included. Most had good premorbid function (median mRS 0) and a median ASPECTS of 9. Large-artery atherosclerosis (44%) and cardioembolism (33%) were the leading etiologies. Clot suction was used in 8 patients, retrievable stents in 4, and cervical angioplasty in 6. The most common combination was clot suction plus angioplasty. Acute carotid stenting was performed in 50%, and carotid revascularization (during admission or planned) in 67%. TICI 3 reperfusion was achieved in 56%. Hemorrhagic transformation occurred in 67%, with one symptomatic intracerebral hemorrhage. Only 18% were discharged home. The remainder required higher-level care or hospice. At 90 days, 33% achieved functional independence (mRS 0–2), and mortality was 18%.

Conclusions:

Despite frequent technical success, clinical recovery in tandem occlusion stroke was modest; larger cohorts are needed to corroborate these findings. The variability in procedures and outcomes highlights the need for tailored strategies and further research, particularly in diverse and underserved populations.