Revascularization strategies in acute stroke with tandem occlusions: The Impact of Dissection vs. Atherosclerotic etiology on Clinical Outcomes

Background and Purpose

The endovascular treatment for tandem occlusion (TO) in anterior circulation acute ischemic stroke represents a major challenge. Tandem occlusion involves an intracranial large vessel occlusion combined with a simultaneous occlusion or high-grade stenosis of the ipsilateral extracranial internal carotid artery. Atherosclerotic carotid artery disease (ACAD) and carotid artery dissection (CAD) are the primary causes. This study aims to assess the effect of etiology on clinical and radiological features, patient outcomes, and complications after revascularization procedures.

Materials and Methods

A retrospective analysis was performed analyzing TO patients who underwent mechanical thrombectomy and percutaneous transluminal angioplasty and stenting at our comprehensive stroke center from January 2019 to July 2023. The study was conducted using chart review and angiogram analysis. Successful reperfusion, peri‑procedural complications, and functional independence at 90 days were collected as outcome measures.

Results

Among the 89 patients, 22 were CAD patients, and 67 were associated with ACAD. CAD patients were significantly younger with a mean age of 55 years compared to 74 years for patients with ACAD (p < 0.001). Additionally, CAD patients exhibited fewer cardiovascular risk factors. Complete revascularization was achieved at a significantly higher rate in CAD patients (72.7 % vs. 40.3 %, p = 0.003). At 90 days post-procedure, CAD patients demonstrated a higher incidence of favorable outcomes (68.2 % vs. 43.2 %, p = 0.038). Multivariate logistic regression analysis identified age as a significant predictor of outcomes (OR = 0.905, 95 % CI: 0.851-0.962, p = 0.001), whereas etiology did not show a statistically significant effect. Furthermore, ACAD patients exhibited a lower incidence of stent occlusion at hospital discharge (3.4 % vs. 25.0 %, p = 0.004).

Conclusion

This study on tandem occlusions found that patients with carotid dissection experienced better clinical outcomes than those with atherosclerotic carotid disease, despite a higher rate of stent reocclusion. However, multivariate analysis indicated that the underlying etiology was not an independent predictor of outcome; instead, patient age and initial stroke severity were more influential factors. Given the increased risk of reocclusion, patients with carotid dissection may benefit from a more individualized antithrombotic strategy to maintain stent patency.