Management of Tandem Cervical Internal Carotid Artery Stenosis and Large Vessel Occlusion During Acute Stroke: A Single Institution's Initial Experience

INTRODUCTION: Thrombectomy for large vessel occlusion (LVO) has become a well-established treatment for acute stroke. Management of tandem internal carotid artery (ICA) stenosis in thrombectomy patients can be challenging, as no formal treatment algorithm exists for this unique pathology. We present a single institution's experience with the acute treatment of ICA stenosis during or after thrombectomy with either carotid artery stent (CAS) or carotid endarterectomy (CEA). METHODS: A retrospective analysis was performed on all patients who underwent thrombectomy with tandem ICA stenosis at our institution. All demographic, stroke presentation, stroke treatment, cervical carotid stenosis treatment, and follow-up data were analyzed for these patients. RESULTS: From 2015 to 2018, 31 patients with tandem ICA stenosis underwent thrombectomy for LVO. Of these patients, 26 had a CAS placed, 25 of which were done at time of thrombectomy, and 1 placed 5 d after thrombectomy. CAS patients were placed on antiplatelet therapy after stent placement. Of the 25 patients who had CAS placed at time of thrombectomy, 5 patients had a symptomatic ICH, 4 of which did not survive the hospitalization. Two additional CAS patients did not survive hospitalization. There were 5 patients who had a CEA performed during the same hospital stay, ranging from 1 to 10 d post-thrombectomy. Patients who underwent CEA had a smaller area of infarct and a shorter thrombectomy procedure time when compared to the CAS patients, and all CEA patients survived hospitalization, with good outcomes. CONCLUSION: CAS placement for tandem ICA stenosis at time of thrombectomy may be less safe than previously published. Early, but not simultaneous, intervention on cervical ICA stenosis after thrombectomy allows for the assessment of infarct volume, patient recovery, and the presence of intracerebral hemorrhage, and thus provides the opportunity to appropriately select patients who would benefit from treatment of the carotid stenosis with either CAS or CEA.