Tandem occlusions treated by endovascular thrombectomy: no difference in outcome between dissection and atherosclerotic cause?

Author: Peter Vanacker, MD PhD, Antwerp University Hospital, Belgium

Endovascular thrombectomy (EVT) of acute stroke related to tandem steno-occlusive lesions in the anterior circulation is technically challenging but may lead to similar outcomes as compared with patients with isolated intracranial occlusions.[1] The potential impact of the two most common carotid steno-occlusive causes (atherosclerotic and dissection) on reperfusion and clinical outcomes after EVT is not clear. These patients were underrepresented in the major RCT’s.[2]  The outcomes of patients with tandem lesions from atherosclerotic and dissection treated with ET in a large individual patient data pooled analysis were compared by the TITAN investigators.[3] They combined patients of 18 comprehensive stroke centers. Tandem occlusions were defined by the combination of a proximal intracranial occlusion and cervical carotid artery high-grade stenosis (NASCET ≥ 90%) or occlusion.

Data of prospectively collected consecutive tandem patients (n=295) treated with endovascular trombectomy were analyzed. A total of 65 patients (22%) were linked to an underlying cervical carotid dissection.

The primary and secondary outcomes, adjusted for the age and NIHSS, were:

  • rate of favorable outcome (mRS 0-2) was 56.3% vs. 47.6% (p=0.85)
  • rate of successful reperfusion (mTICI 2b-3) was 78.5% vs. 74.5% (p=0.13)
  • symptomatic intracerebral hemorrhage was 4.5% vs. 5.2% (p=1.0)
  • 90-day mortality were 7.8% vs. 15.3% (p=0.94)
  • median procedural time was 76 vs. 67 min

To conclude, acute ischemic stroke patients with tandem steno-occlusive disease, irrespective of the underlying pathophysiological mechanism (arteriosclerotic vs. dissection), treated with endovascular thrombectomy have similar 90-day clinical outcomes and safety outcomes. Carotid stenting (alone or combined with angioplasty) was performed in more than 60% of atherosclerotic tandem-occlusions and more than 50% in dissections, with similar clinical outcomes. The latter indication is questionable in case of good developed collaterals, as stent-trombosis and reperfusion injury need to be feared.[4]


[1] Goyal M, Menon BK, van Zwam WH, et al. HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomized trials. Lancet 2016;387:1723-1731.
[2] Sivan-Hoffmann R, Gory B, Amoiry X, et al Stent-retriever thrombectomy for acute anterior ischemic stroke with tandem occlusion: a systematic review and meta-analysis. Eur Radiol 2017;27:247-254
[3] Gory B, Piotin M, Haussen DC, et al., on behalf of the TITAN Investigators. Thrombectomy in Acute Stroke With Tandem Occlusions From Dissection Versus Atherosclerotic Cause. Stroke. 2017;48:3145-3148
[4] Moulakakis KG, Mylonas SN, Lazaris A, et al. Acute Carotid Stent Thrombosis: A Comprehensive Review. Vasc Endovascular Surg. 2016;50(7):511-521.