Abstract 088: Endovascular Treatment for Acute Tandem Occlusion Stroke, a single center experience

Background/purpose Tandem occlusions remain underrepresented in major stroke randomized controlled trials. Although endovascular thrombectomy is standard of care in patients with acute ischemic and large vessel occlusion, optimal management in tandem occlusion in unsettled. We reviewed anterior‐circulation tandem occlusion cases treated with thrombectomy to detail procedural strategies and clinical outcomes. Methods This retrospective chart review included 9 patients with acute anterior circulation tandem ischemic stroke who underwent endovascular therapy at a single center between January 2022 and September 2024. Patients were identified from a prospective database of large‐vessel occlusions (LVO). Tandem occlusion was defined as simultaneous obstruction of the extracranial cervical internal carotid artery (ICA) and a large intracranial artery, typically the terminal ICA or proximal middle cerebral artery (MCA). The study population was predominantly Latino/Hispanic. Collected data included demographics, clinical presentation (including baseline NIHSS), imaging findings (occlusion location and degree of ICA stenosis), and procedural details such as thrombectomy strategy, carotid stenting, time metrics, and periprocedural complications. The primary outcome was the modified Rankin Scale (mRS) score at 90 days; discharge disposition and in‐hospital mortality, were secondary outcomes. Results Among nine patients with anterior circulation tandem occlusions, the mean age was 71.4 years (±SD 11.16), and 66.7% were male. Premorbid functional status was favorable, with a median modified Rankin Scale (mRS) score of 0 (IQR 0‐0.75). Stroke etiology was most commonly large‐artery atherosclerosis (n=4), followed by cardioembolism (n=3), with one case each due to other determined etiology and cryptogenic stroke. The median ASPECTS on admission was 9 (IQR 8.5‐10). Clot suction devices were the most used intervention, administered to 8 patients. Retrievable stents were used in 4 patients. Cervical carotid angioplasty was performed in 6 patients. The most frequent treatment combination was clot suction with cervical carotid angioplasty, observed in 4 patients. Notably, one patient received a combination of three modalities: retrievable stent, clot suction, and cervical carotid angioplasty. During treatment, acute carotid artery stenting was performed in 50% of cases, and carotid revascularization—either during admission or planned post‐discharge—was undertaken in 66.7%. Successful reperfusion (TICI 3) was achieved in 55.6% of patients, while partial reperfusion (TICI 2C, 2A, or 1) occurred in three out of the nine patients, and one patient of the nine had no reperfusion (TICI 0). There were six instances of hemorrhagic transformation, including only one case of symptomatic intracerebral hemorrhage. Following treatment, 2 patients were discharged home, while the rest required higher‐level care: 3 to acute care, 3 to other facilities, and 1 to hospice. At 90 days, 3 patients achieved functional independence (mRS 0‐2), with an overall mortality rate 2 out of 9. Conclusion In this case series of nine patients with tandem occlusions demonstrated a high rate of complete reperfusion (TICI 2B or higher), yet discharge outcomes remained poor, and in‐hospital mortality reached 18.2%. Carotid revascularization and acute stenting were variably applied, reflecting ongoing clinical uncertainty in managing the extracranial component of tandem occlusions. These findings highlight the complexity and treatment challenges associated with this stroke subtype.