What is the clinical evidence from this study?

Study design: Review. Population: Acute ischaemic stroke with tandem lesions. Intervention: Immediate carotid artery stenting during endovascular thrombectomy vs. Deferred treatment.

What does this research mean for the field?

Immediate carotid artery stenting during endovascular thrombectomy for acute ischemic stroke with tandem lesions shows potential benefits, but robust randomized controlled trial data are currently lacking to establish definitive guidelines. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

December 19, 2023Open Access

Immediate Carotid Artery Stenting or Deferred Treatment in Patients With Tandem Carotid Lesions Treated Endovascularly for Acute Ischaemic Stroke

Key Result

Immediate carotid artery stenting during endovascular thrombectomy for acute ischemic stroke with tandem lesions shows potential benefits in registries, but lacks robust randomized controlled trial data to establish definitive guidelines.

Structured PICO

Does immediate carotid artery stenting during endovascular thrombectomy improve functional outcomes in patients with acute ischaemic stroke and tandem lesions?

Population

Patients with an acute ischaemic stroke having a tandem lesion defined by the combination of an intracranial large vessel thrombo-embolic occlusion and a high grade stenosis or occlusion of the ipsilateral internal carotid artery.

Intervention

Immediate carotid artery stenting (CAS) during endovascular thrombectomy (EVT) along with dual antiplatelet therapy.

Comparator

Deferred treatment strategy for the extracranial carotid artery lesion (carotid endarterectomy, carotid artery stenting, or best medical management alone) within two weeks of the initial event.

Outcome

Functional outcome at 90 days, assessed by the modified Rankin scale (mRS).hard clinical

Observational data suggest that immediate carotid artery stenting during endovascular thrombectomy for tandem lesions may improve functional outcomes and re-perfusion rates, but ongoing randomized trials are needed to establish definitive treatment guidelines.

Limitations

Absence of data from robust randomized controlled trials hampers firm recommendations about optimal management.
Consensus regarding the antithrombotic management for carotid stent placement in the setting of endovascular stroke treatment is lacking.
Retrospective studies show highly variable rates of intracranial haemorrhage.

Abstract

Fifteen to 20% of patients with an acute ischaemic stroke have a tandem lesion defined by the combination of an intracranial large vessel thrombo-embolic occlusion and a high grade stenosis or occlusion of the ipsilateral internal carotid artery. These patients tend to have worse outcomes than patients with isolated intracranial occlusions, with higher rates of disability and death. The introduction of endovascular thrombectomy to treat the intracranial lesion clearly improved the outcome compared with treatment with intravenous thrombolysis alone. However, the best treatment strategy for managing the extracranial carotid artery lesion in patients with tandem lesions remains unknown. Current guidelines recommend carotid endarterectomy for patients with transient ischaemic attack or non-disabling stroke and moderate or severe stenosis of the internal carotid artery, within two weeks of the initial event, to prevent major stroke recurrence and death. Alternatively, the symptomatic carotid artery could be treated by endovascular placement of a stent during endovascular thrombectomy (EVT). This would negate the need for a second procedure, immediately reduce the risk of stroke recurrence, increase patient satisfaction, and could be cost effective. However, the administration of dual antiplatelet therapy could potentially increase the risk of symptomatic intracranial haemorrhage in patients with acute ischaemic stroke. Randomised controlled trials evaluating the efficacy and safety of immediate carotid artery stenting during EVT in acute stroke patients with tandem lesions are currently ongoing and will impact the current guidelines regarding the treatment of patients with acute ischaemic stroke due to these tandem lesions. • Tandem lesions occur in approximately 15–20% of patients with an acute ischaemic stroke. • These patients have higher rates of disability and death compared to patients with isolated intracranial occlusions. • The best treatment strategy for the extracranial internal carotid artery lesion remains unknown. • Carotid artery stenting during EVT could immediately reduce the risk of recurrent stroke. • RCT’s evaluating the efficacy and safety of CAS during EVT in tandem lesion patients are currently ongoing.

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