Tandem Lesion Strokes: To Stent or Not to Stent, Insights From a Decade of Experience at a Comprehensive Stroke Center in Argentina

BACKGROUND: Tandem lesion strokes, defined by the coexistence of an intracranial large- or medium-vessel occlusion and a cervical internal carotid artery stenosis or occlusion, represent a challenging subtype of acute ischemic stroke. Optimal endovascular management remains controversial, particularly regarding the role of emergent carotid artery stenting (eCAS) during mechanical thrombectomy (MT). We aim to compare the safety and efficacy of eCAS versus MT alone in patients with anterior circulation tandem lesion strokes treated at a comprehensive stroke center. METHODS: We conducted a retrospective observational cohort study of consecutive adult patients with anterior circulation tandem lesion strokes treated with MT within 24 hours of symptom onset between January 2015 and July 2025. Patients were categorized according to treatment strategy: eCAS performed during thrombectomy or MT alone. The primary efficacy outcome was the ordinal shift in the 90-day modified Rankin Scale score. Secondary efficacy outcomes included excellent outcome (modified Rankin Scale score of 0–1), functional independence (modified Rankin Scale score of 0–2) at 90 days, and successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b). Primary safety outcomes included symptomatic intracranial hemorrhage, in-hospital mortality, and 90-day mortality. RESULTS: A total of 111 patients were included (mean age, 71.2±12.6 years; 68.5% male), of whom 74 (67%) underwent eCAS, and 37 (33%) received MT alone. Ordinal logistic regression demonstrated a nonsignificant trend toward better functional outcomes with eCAS. This subgroup achieved higher rates of successful recanalization (97.3% versus 78.4%; odds ratio, 13.26 95% CI, 2.13–82.49; P =0.006) and excellent functional outcomes at 90 days (41.9% versus 12.5%; odds ratio, 6.80 95% CI, 1.35–34.20; P =0.020). Rates of symptomatic intracranial hemorrhage, early neurological deterioration, and mortality did not differ significantly between groups. CONCLUSIONS: In this single-center experience, emergent eCAS was associated with higher reperfusion rates and improved functional outcomes, without an increased risk of symptomatic hemorrhage or mortality. Prospective randomized controlled trials are warranted to establish standardized management guidelines for this complex stroke subtype.