Article Text

Download PDFPDF
Original research
Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis
  1. Francesco Diana1,
  2. Michele Romoli2,
  3. Giada Toccaceli3,
  4. Aymeric Rouchaud4,5,
  5. Charbel Mounayer4,5,
  6. Daniele Giuseppe Romano1,
  7. Francesco Di Salle6,
  8. Paolo Missori7,
  9. Andrea Zini8,
  10. Diana Aguiar de Sousa9,
  11. Simone Peschillo10,11
  1. 1Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d’Aragona', Salerno, Italy
  2. 2Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy
  3. 3Emergency Neurosurgery, Ospedale Civile 'Santo Spirito', Pescara, Italy
  4. 4Interventional Neuroradiology, University Hospital Centre of Limoges, Limoges, France
  5. 5BioEMXLim, University of Limoges Medical Faculty, Limoges, France
  6. 6Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Fisciano, Italy
  7. 7Human Neurosciences, Neurosurgery, University of Rome La Sapienza, Rome, Italy
  8. 8Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
  9. 9Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/CHULN, University of Lisbon, Santa Maria, Portugal
  10. 10Surgical Medical Sciences and Advanced Technologies "G.F. Ingrassia" - Endovascular Neurosurgery, University of Catania, Catania, Italy
  11. 11Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
  1. Correspondence to Dr Francesco Diana, Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d’Aragona', 84131 Salerno, Campania, Italy;{at}


Background Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear.

Objective To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion.

Methods Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0–2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b–3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling.

Results Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors.

Conclusions In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.

  • Stroke
  • Stent
  • Stenosis
  • Intervention
  • Angioplasty

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.

View Full Text


  • AZ, DAdS and SP are joint senior authors.

  • Twitter @fdianamd

  • Correction notice Since this paper was first published, figure 3 has been updated, because an article was wrongly included in the analysis. The OR, 95 CI and weight categories have been updated. However, point estimate remains unchanged, and only a minor change to 95%CI emerged.

  • Contributors Conception and design of the work: FD. Data acquisition: FD and GT. Data analysis and interpretation: FD, MR, DAdS. Drafting the work: FD, MR, AR, CM, DGR, FDS, PM. Critical revision: DAdS, AZ, and SP. Final approval: all authors.

  • 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.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Linked Articles