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Original research
Endovascular treatment of acute tandem lesions in patients with mild anterior circulation stroke
  1. Lukas Meyer1,
  2. Maria Politi2,3,
  3. Maria Alexandrou2,
  4. Christian Roth2,
  5. Andreas Kastrup4,
  6. Anastasios Mpotsaris5,
  7. Uta Hanning1,
  8. Fabian Flottmann1,
  9. Caspar Brekenfeld1,
  10. Milani Deb-Chatterji6,
  11. Goetz Thomalla6,
  12. Helge Kniep1,
  13. Tobias D Faizy1,
  14. Matthias Bechstein1,
  15. Gabriel Broocks1,
  16. Moriz Herzberg7,8,
  17. Katharina Feil9,10,
  18. Lars Kellert9,
  19. Franziska Dorn8,11,
  20. Kamil Zeleňák12,
  21. Jens Fiehler1,
  22. Panagiotis Papanagiotou2,13
  23. for the German Stroke Registry-Endovascular Treatment (GSR-ET)
    1. 1 Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
    2. 2 Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
    3. 3 Interventional Radiology Unit, Evangelismos General Hospital, Athens, Greece
    4. 4 Department of Neurology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
    5. 5 Department of Diagnostic and Interventional Neuroradiology, University Hospital of Magdeburg, Magdeburg, Germany
    6. 6 Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
    7. 7 Department of Radiology, University Hospital Würzburg, Würzburg, Germany
    8. 8 Institute of Neuroradiology, Ludwig Maximilians Universität, München, Germany
    9. 9 Department of Neurology, Ludwig Maximilians Universität, München, Germany
    10. 10 Department of Neurology and Stroke, Eberhard-Karls University, Tübingen, Germany
    11. 11 Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
    12. 12 Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
    13. 13 Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
    1. Correspondence to Dr Lukas Meyer, Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany; lu.meyer{at}


    Background In patients with mild strokes the risk–benefit ratio of endovascular treatment (EVT) for tandem lesions has yet to be evaluated outside of current guideline recommendations. This study investigates the frequency as well as procedural and safety outcomes in daily clinical practice.

    Methods Using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) we analyzed patients with anterior circulation stroke due to tandem-lesions and mild deficits. These patients were defined as ≤5 on the National Institutes of Health Stroke Scale (NIHSS). Recanalization was assessed with the modified Thrombolysis in Cerebral Infarction Scale (mTICI). Early neurological and long-term functional outcomes were assessed with the NIHSS change and modified Rankin scale (mRS), respectively. Safety assessment included periprocedural complications and the rate of symptomatic intracerebral hemorrhage (sICH).

    Results A total of 61 patients met the inclusion criteria and were treated endovascularly for tandem lesions. The median age was 68 (IQR:59–76) and 32.9% (20) were female. Patients were admitted to the hospital with a median NIHSS score of 4 (IQR:2–5) and a median Alberta Stroke Programme Early CT Score (ASPECTS) of 9 (IQR:8–10). Successful recanalization (mTICI 2b-3) was observed in 86.9% (53). NIHSS decreased non-significantly (p=0.382) from baseline to two points (IQR:1–9) at discharge. Excellent (mRS≤1) and favorable (mRS≤2) long-term functional outcome at 90-days was 55.8% (29) and 69.2% (36), respectively. Mortality rates at 90-days were 9.6% (5) and sICH occurred in 8.2% (5).

    Conclusions EVT for tandem lesions in patients with mild anterior circulation stroke appears to be feasible but may lead to increased rates of sICH. Further studies comparing endovascular with best medical treatment (BMT) especially investigating the risk of periprocedural hemorrhagic complications, are needed.

    • Stroke
    • Thrombectomy
    • Thrombolysis

    Data availability statement

    Data are available upon reasonable request. Data are available upon reasonable request and after approval of the GSR-ET Steering committee.

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    Data availability statement

    Data are available upon reasonable request. Data are available upon reasonable request and after approval of the GSR-ET Steering committee.

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    • Collaborators On behalf of the German Stroke Registry - Endovascular Treatment (GSR - ET): Tobias Boeckh-Behrens, Silke Wunderlich, Arno Reich, Anastasios Mpotsaris, Martin Wiesmann, Ulrike Ernemann, Till-Karsten Hauser, Christian H Nolte, Eberhard Siebert, Sarah Zweynert, Georg Bohner, Alexander Ludolph, Karl-Heinz Henn, Waltraud Pfeilschifter, Marlis Wagner, Joachim Röther, Bernd Eckert, Jörg Berrouschot, Albrecht Bormann, Anna Alegiani, Jens Fiehler, Fabian Flottmann, Christian Gerloff, Götz Thomalla, Elke Hattingen, Gabor Petzold, Sven Thonke, Christopher Bangard, Christoffer Kraemer, Martin Dichgans, Marios Psychogios, Jan Liman, Martina Petersen, Florian Stögbauer, Peter Kraft, Mirko Pham, Michael Braun, Gerhard F. Hamann, Andreas Kastrup, Christian Roth, Klaus Gröschel, Timo Uphaus, Volker Limmroth

    • Contributors LM, and PP made substantial contributions to the conception, design of the work, and take full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. Data analysis was performed by LM and PP. Interpretation of the data was done by LM, JF, GB, MB, MP, and PP. LM and PP drafted the manuscript and all other authors revised it critically for important intellectual content. All authors approved the final version to be published. They agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the manuscript are appropriately investigated and resolved.

    • 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 J. Fiehler: research support from the German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions-/Förderbank (IFB), Medtronic, Microvention, Philips, Stryker; consultancy appointments; Acandis, Bayer, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD Clinicals, Medtronic, Medina, Microvention, Penumbra, Route92, Stryker, Transverse Medical; stock holdings for Tegus, JNIS Associate Editor.

      F. Dorn: Associate Editor for JNIS and JCM; Research funding from Cerenovus/ Johnson&Johnson; Consulting for Cerenovus, Balt, Cerus Endovascular; Speaker, Acandis, Stryker; Payment for expert testimony for Cerenovus; Advisory Board Cerenovus.

      T. Faizy: Eppdata GmbH; German Research Foundation Scholarship Grant.

      L. Meyer: Compensation as a speaker for Balt Prime.

      G. Broocks: Compensation as a speaker for Balt Prime

      L. Kellert: AstraZeneca, Bayer Vital, Boehringer Ingelheim, Bristol-Meyer-Squibb, Daiichi Sankyo, and Pfizer K. Feil: Intramurale AKF Förderung UKT; Böhringer Ingelheim LEXI; Pfizer.

      H. Kniep: Permanent consultant with Eppdata GmbH, Hamburg, Germany; Anonymous funding for participating at ESMINT congress 2022 (travel, accommodation).

      G. Thomalla: EU: TENSION trial, EU: PRECIOUS trial, German Innovation Fund: StroCare, Acandis, Stryker, Alexion, Amarin, Bayer, Boehringer Ingelheim BristolMyersSquibb/Pfizer, Daiichi Sankyo, ESO board of directors, DGN guideline writing group

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

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