Carotid artery stenting or carotid endarterectomy for residual significant stenosis after thrombectomy in acute tandem occlusion stroke?

A 82‐year‐old male presented with right‐sided hemiplegia and aphasia. CT‐scan showed hyperdensity of the left middle cerebral artery (MCA). CT‐angiography revealed occlusion of the left MCA and intra‐cranial internal carotid artery (ICA) in combination with occlusion of the left extra‐cranial ICA. Complete recanalization of intra‐cranial vessels was obtained after thrombectomy within 6 h from symptom onset, but residual significant extra‐cranial stenosis remained. Non‐contrast CT‐scan after thrombectomy revealed large hyperdensities secondary to contrast extravasation in the left MCA territory. Residual extra‐cranial ICA stenosis was not treated with emergent stenting. At 24 h, NIHSS score was 0, but follow‐up CT‐scan showed an ischemic lesion with spontaneous hemorrhagic transformation. A single antiplatelet treatment was reintroduced after 24 h and carotid endarterectomy was done without complications after 2 weeks.