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Tandem occlusions in acute ischemic stroke – impact of antithrombotic medication and complementary heparin on clinical outcome and stent patency
  1. Ulf Neuberger1,
  2. Konstantina Moteva1,
  3. Dominik F Vollherbst1,
  4. Silvia Schönenberger2,
  5. Tilman Reiff2,
  6. Peter Arthur Ringleb2,
  7. Martin Bendszus1,
  8. Johannes Alex Rolf Pfaff1,
  9. Markus Möhlenbruch1
  1. 1 Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
  2. 2 Neurology, Heidelberg University Hospital, Heidelberg, Germany
  1. Correspondence to Dr Markus Möhlenbruch, Neuroradiology, Heidelberg University Hospital, Heidelberg 69120, Germany; markus.moehlenbruch{at}


Background and purpose Mechanical thrombectomy (MT) and acute carotid stenting (ACS) of patients with acute ischemic stroke due to tandem occlusions (TO) of the anterior circulation was proven to be safe and effective, but the implications of periprocedural antithrombotic medications are only known to a limited extent.

Methods We conducted a retrospective analysis of 162 consecutive patients who presented with TO and were treated with MT and ACS in our center. Patients initially either received dual antiplatelet therapy (DAT) or tirofiban periprocedurally. Some patients were also treated with unfractionated heparin. The frequency of intracranial hemorrhages (ICH), as well as the impact on clinical outcome and stent patency of different medical regimes, were evaluated using univariate tests and adjusted multivariate logistic regressions.

Results Patients who received supportive treatment with heparin had significantly higher occurrences of any (OR, 2.46; 95% CI, 1.15 to 5.28) and symptomatic ICH (OR, 3.71; 95% CI, 1.18 to 14.95). Additionally, these patients were less likely to have a moderate clinical outcome after 90 days (modified Rankin scale 0–3; OR, 0.33; 95% CI, 0.15 to 0.72), but were more likely to have a fatal outcome after 90 days (OR, 2.84; 95% CI 1.10 to 7.31). These findings persisted in patients who received both DAT and heparin, but not for patients who received both tirofiban and heparin.

Conclusion Supportive administration of heparin in patients with TO and treatment with MT and ACS should be carefully considered, especially in patients who primarily receive DAT.

  • intervention
  • stroke
  • thrombectomy
  • hemorrhage
  • stent

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  • Contributors UN, KM, and MM conceived and designed the research. UN, KM, DFV, SS, TR, PAR, JARP, and MM acquired and analyzed the data. UN performed statistical analysis. UN prepared the first draft of the report. All authors made critical revisions of the manuscript for important intellectual content and approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The stroke database was approved by the local ethics committee. As this was a retrospective analysis, additional written informed consent was waived.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Data are available upon reasonable request from the corresponding author.