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Original research
Emergent stent-assisted angioplasty of extracranial internal carotid artery and intracranial stent-based thrombectomy in acute tandem occlusive disease: technical considerations
  1. José E Cohen1,3,
  2. Moshe Gomori3,
  3. Gustavo Rajz4,
  4. Samuel Moscovici1,
  5. Ronen R Leker2,
  6. Shai Rosenberg2,
  7. Eyal Itshayek1
  1. 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
  2. 2Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
  3. 3Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
  4. 4Department of Neurosurgery, Sheba Medical Center, Tel Aviv, Israel
  1. Correspondence to Professor J E Cohen, Department of Neurosurgery, Hadassah-Hebrew University Medical Center, PO Box 12000, Jerusalem 91120, Israel; jcohenns{at}


Objective Tandem occlusions of the internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous thrombolytic therapy, and are usually managed by endovascular means. This study describes experience with stent-assisted endovascular ICA revascularization and stent-based thrombectomy.

Methods In patients with tandem ICA–middle cerebral artery (MCA)/distal ICA occlusion, the carotid occlusion was recanalized by primary angioplasty and stent implantation, and the distal occlusion by stent-based thrombectomy. Two variant techniques are described.

Results Seven consecutive patients, mean age 64.1 years (range 49–75) and mean admission National Institutes of Health Stroke Scale score of 23, were included. Occlusion sites were tandem proximal ICA and MCA trunk (six patients) and tandem proximal left ICA and ICA terminus (one patient). Complete recanalization with complete perfusion (Thrombolysis in Myocardial Infarction [TIMI] 3, Thrombolysis in Cerebral Infarction [TICI] 3) was achieved in six patients and partial recanalization with partial perfusion (TIMI 2, TICI 2A) in one. Mean time to therapy was 4.9 h (range 3–6.5); mean time to recanalization was 55 min (range 38–65 min). CT performed 1 day after recanalization showed cortical sparing (>90% of the cortex at risk) in seven patients. Five patients (72%) presented with good clinical outcome (modified Rankin Scale (mRS) score 0–2) at 1 month; one patient (patient No 7) reached an mRS score of 3 and one patient died.

Conclusions In selected cases of acute ICA occlusion and concomitant major vessel embolic stroke, angioplasty and stenting of the proximal occlusion and stent-based thrombectomy of the intracranial occlusion may be feasible, effective and safe, and provide early neurological improvement. Further experience and prospective studies are warranted.

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