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Original research
Endovascular treatment of tandem vascular occlusions in acute ischemic stroke
  1. Ajit S Puri1,
  2. Anna L Kühn1,
  3. Hyon-Jo Kwon2,
  4. Muhib Khan3,
  5. Samuel Y Hou1,
  6. Eugene Lin4,
  7. Juyu Chueh1,
  8. Imramsjah MJ van der Bom1,
  9. Guilherme Dabus4,
  10. Italo Linfante4,
  11. Matthew J Gounis1,
  12. Ajay K Wakhloo1
  1. 1Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
  2. 2Cerebrovascular Center, Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
  3. 3Departments of Neurology, University of Massachusetts, Worcester, Massachusetts, USA
  4. 4Baptist Cardiac and Vascular Institute, Baptist Neuroscience Center, Florida International University, Miami, Florida, USA
  1. Correspondence to Dr Ajit S Puri, Division of Neuroimaging and Intervention and New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA; ajit.puri{at}


Background and purpose Tandem vascular occlusions are an important cause of acute ischemic stroke (AIS) and present unique treatment challenges. We report our experience of managing a subset of AIS patients with extracranial vascular stenting/angioplasty and intracranial revascularization.

Methods Consecutive patients who presented at three centers with AIS from tandem vascular occlusions confirmed by brain and neck CT imaging were included in the study. We retrospectively analyzed the patient demographics, National Institute of Health Stroke Scale (NIHSS) score and modified Rankin Scale (mRS) score at the time of admission, treatment strategy, angiographic results using the Thrombolysis In Cerebral Infarction (TICI) score, and clinical and imaging follow-up.

Results Twenty-eight patients were included. The mean NIHSS score at admission was 18. Extracranial carotid occlusions with a concomitant middle cerebral artery occlusion were seen in 89.3% of patients (n=25) and vertebral artery combined with basilar artery lesions in 10.7% (n=3). An antegrade approach (ie, treatment of the extracranial lesion first) was used in 24 patients (85.7%). Proximal occlusion recanalization was achieved usually with a stent (n=27; 96.4%). Pursuant to intracranial revascularization techniques, ≥TICI 2A recanalization was seen in 96.4% of patients. An mRS score of ≤2 at 90 days was achieved in 56.5% of patients.

Conclusions Our study shows preliminary data from three centers on recanalization of tandem occlusions in patients presenting with AIS. There was a preference to revascularize the proximal occlusion using a stent followed by distal recanalization with mechanical thrombectomy, intra-arterial thrombolysis or a combination of these. This approach has low periprocedural complications and can achieve an excellent angiographic and clinical outcome.

  • Stroke
  • Stent

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