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Original research
Proximal Internal Carotid artery Acute Stroke Secondary to tandem Occlusions (PICASSO) international survey
  1. Cynthia B Zevallos1,
  2. Mudassir Farooqui1,
  3. Darko Quispe-Orozco1,
  4. Alan Mendez-Ruiz1,
  5. Mary Patterson2,
  6. Kristine Below2,
  7. Sheila O Martins3,
  8. Ossama Y Mansour4,
  9. Francisco Mont’Alverne5,
  10. Thanh N Nguyen6,
  11. Luis Lemme7,
  12. Adnan H Siddiqui8,9,
  13. Justin F Fraser10,
  14. Ashutosh P Jadhav11,
  15. Osama O Zaidat12,
  16. Santiago Ortega-Gutierrez13
  1. 1 Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  2. 2 Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
  3. 3 Neurology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
  4. 4 Neurology, Stroke and NeuroInterventional Unit, Alexandria University Faculty of Medicine, Alexandria, Egypt
  5. 5 Interventional Neuroradiology, Hospital General de Fortaleza, Fortaleza, Brazil
  6. 6 Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
  7. 7 Interventional Neuroradiology, Centro Endovascular Neurologico Buenos Aires, Buenos Aires, Argentina
  8. 8 Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
  9. 9 Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
  10. 10 Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
  11. 11 Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  12. 12 Neuroscience, St Vincent Mercy Hospital, Toledo, Indiana, USA
  13. 13 Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  1. Correspondence to Dr Santiago Ortega-Gutierrez, Division of Neurointerventional Surgery-Interventional Neuroradiology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA; santy-ortega{at}


Background While mechanical thrombectomy (MT) is the standard of care for large vessel occlusion strokes, the optimal management of tandem occlusions (TO) remains uncertain. We aimed to determine the current practice patterns among stroke physicians involved in the treatment of TO during MT.

Methods We distributed an online survey to neurovascular practitioners (stroke neurologists, neurointerventionalists, neurosurgeons, and radiologists), members of professional societies. After 2 months the site was closed and data were extracted and analyzed. We divided respondents into acute stenting and delayed treatment groups and responses were compared between the two groups.

Results We received 220 responses from North America (48%), Latin America (28%), Asia (15%), Europe (5%), and Africa (4%). Preferred timing for cervical revascularization varied among respondents; 51% preferred treatment in a subsequent procedure during the same hospitalization whereas 39% preferred to treat during MT. Angioplasty and stenting (41%) was the preferred technique, followed by balloon angioplasty and local aspiration (38%). The risk of intracerebral hemorrhage was the most compelling reason for not stenting acutely (68%). There were no significant differences among practice characteristics and timing groups. Most practitioners (70%) agreed that there is equipoise regarding the optimal endovascular treatment of cervical lesions in TO; hence, 77% would participate in a randomized controlled trial.

Conclusions The PICASSO survey demonstrates multiple areas of uncertainty regarding the medical and endovascular management of TOs. Experts acknowledged the need for further evidence and their willingness to participate in a randomized controlled trial to evaluate the best treatment for the cervical TO lesion.

  • stenosis
  • stroke
  • stent
  • intervention
  • standards

Data availability statement

Data are available upon reasonable request to the corresponding author.

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Data availability statement

Data are available upon reasonable request to the corresponding author.

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  • Twitter @ossama_mansour, @CerebrosvascLab

  • Contributors Conceptualization: SO-G, OOZ, CBZ, MF. Data collection and analysis: CBZ, MF, DQ-O, AM-R, MP, KB. Writing - original draft: CBZ. Writing - review and editing: SO-G, MF, MP, SOM, OM, FMA, TNN, LL, AHS, JFF, APJ, OOZ.

  • 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.

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  • Competing interests SO-G: Consultant for Medtronic and Stryker Neurovascular. OOZ: Consultant and speaker for Cerenovus, Stryker, Penumbra, and Medtronic. TNN: Research support from Medtronic. SOM: Consultant for Bayer, Medtronic, Pfizer, and Boehringer Ingelheim. FMA: Consultant for Balt USA, Medtronic, MicroVention, Penumbra, and Stryker. AHS: Consultant for Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA, Cerebrotech Medical Systems, Cerenovus, Corindus, Endostream Medical, Imperative Care, Integra LifeSciences Corp, Medtronic, MicroVention, Minnetronix Neuro, Northwest University–DSMB Chair for HEAT Trial, Penumbra, Q’Apel Medical, Rapid Medical, Rebound Therapeutics Corp (purchased by Integra LifeSciences Corp), Serenity Medical, Silk Road Medical, StimMed, Stryker, Three Rivers Medical, VasSol, W L Gore & Associates. JFF: Consultant for Stream Biomedical, Penumbra and Medtronic Neurovascular.

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

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