Introduction: The Clinical Conundrum of Tandem Lesions
Acute ischemic stroke involving tandem lesions—defined as a high-grade stenosis or occlusion of the extracranial internal carotid artery (ICA) associated with a concurrent distal intracranial occlusion—represents one of the most complex challenges in neurointerventional surgery. Approximately 15% to 25% of patients presenting with anterior circulation large vessel occlusions (LVO) exhibit this dual-level pathology. Historically, these patients have been under-represented in the pivotal randomized controlled trials that established the efficacy of endovascular thrombectomy (EVT), leading to significant heterogeneity in management strategies.
The primary debate centers on the extracranial component: should the carotid lesion be treated emergently with stenting (eCAS) during the thrombectomy procedure, or should it be managed conservatively with balloon angioplasty or medical therapy alone? Concerns regarding the need for immediate dual antiplatelet therapy (DAPT) and the potential for increased symptomatic intracranial hemorrhage (sICH) have long tempered the enthusiasm for emergent stenting. However, the CERES-TANDEM study, an international multicenter longitudinal retrospective cohort study, now provides the most robust evidence to date supporting the benefits of eCAS in this high-risk population.
