Background and purpose The optimal treatment in the acute phase of cervical internal carotid artery (CICA) occlusion associated with carotid “T” or middle cerebral artery obstruction is a matter of debate. In this study, we report our experience using endovascular mechanical thrombectomy and synchronous intravenous fibrinolysis.

Patients and Methods we examined all cases of tandem occlusion treated in our institution between November 2009 and November 2010. The proximal occlusion was treated using manual thromboaspiration without stenting in order to achieve intracranial recanalization as rapid as possible. When necessary, stenting was performed after the reconstitution of the intracranial vessel. Morphological and clinical results were recorded in the immediate post-operative phase and at the 3-month follow-up. Clinical success was defined as final NIHSS=1 or improvement of ≥10 points from the baseline score.

Results Four men and six women were treated (mean age 66 years). Three patients underwent standalone MTB because of contra-indications to intravenous fibrinolysis. The cervical internal carotid artery was recanalized in all cases and the intracranial vessel (TICI≥2b) in eight. Adverse events were recorded in four patients of which three were asymptomatic. These included 2 cases of subarachnoid hemorrhage, one case of traumatic dissection and collateral artery embolism, and one case of fatal intra-cerebral hemorrhage 7 days after the procedure. At the 3-month follow-up a mRS≤2 was observed in four patients.

Conclusion The described approach for the treatment of tandem occlusions is effective with regard to morphological and clinical assessments and thus may be considered as a valid tool in acute stroke.