Acute Cervical Carotid Management During Thrombectomy for Tandem Occlusion: A Systematic Review and Network Meta-Analysis

Background/Objectives: The optimal cervical carotid strategy during thrombectomy for anterior-circulation tandem occlusion remains uncertain. We compared emergent carotid stenting, balloon angioplasty alone, and no targeted acute cervical revascularization. Methods: We searched PubMed, Ovid Embase, Cochrane CENTRAL, Web of Science, and Scopus for comparative studies published from January 2015 to 25 August 2026. A frequentist random-effects network meta-analysis estimated odds ratios (ORs) and 95% confidence intervals (CIs), with outcome-specific cohort-overlap auditing. The event-count network was exploratory; adjusted evidence was analyzed separately. Risk of bias was assessed using RoB 2 or ROBINS-I-aligned domains; confidence was assessed with CINeMA. PROSPERO registration: CRD420261494924. Results: The review included 60 reports representing 49 cohort or report families. Fifteen cohorts contributed 1556 patients for functional independence and 15 contributed 1676 for symptomatic intracranial hemorrhage (sICH). Stenting was associated with greater 90-day functional independence than angioplasty alone (OR, 1.73; 95% CI, 1.22–2.45), without a detected difference in sICH (OR, 1.01; 95% CI, 0.60–1.67). All leave-one-cohort-out functional estimates remained above 1, with 95% CIs excluding 1. Evidence was predominantly nonrandomized. Conclusions: Emergent carotid stenting was associated with greater 90-day functional independence than balloon angioplasty alone, with no detected difference in sICH. Serious or critical risk of bias in all studies in the strict network limits causal interpretation. Imprecision and heterogeneous antiplatelet protocols preclude establishing noninferiority or excluding increased hemorrhagic risk.