Tandem Lesions in Anterior Circulation Stroke Analysis of the German Stroke Registry-Endovascular Treatment

Background and Purpose: Tandem lesions in the anterior circulation account for up to 30% of all large vessel occlusion strokes. The optimal periprocedural approach in these lesions is still a matter of debate. Methods: Data from the German Stroke Registry-Endovascular Treatment between June 2015 and December 2019 were analyzed. The German Stroke Registry-Endovascular Treatment is an academic, independent, prospective, multicenter, observational registry study with 25 participating stroke centers from all over Germany enrolling consecutive mechanical thrombectomy patients. Tandem lesions were defined as a combination of a relevant extracranial internal carotid artery (ICA) pathology (ipsilateral stenosis >70% or occlusion) and concomitant intracranial large vessel occlusion. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score of 2b-3. The modified Rankin Scale score of 0 to 2 at 3 months indicated good outcome. The aim of this study was to investigate the safety and efficacy of different technical strategies in tandem lesions. Results: Out of 6635 patients, 874 (13.2%) presented with tandem lesions. Of these, 607 (69.5%) underwent acute treatment of the extracranial ICA. Acute treatment of the extracranial ICA lesion led to a higher probability of successful reperfusion (odds ratio, 40.63 [95% CI, 30.03-70.06]) compared with patients who did not undergo acute treatment of the extracranial ICA lesion and was associated with good clinical outcome (39.5% versus 29.3%, P<0.001) and a lower rate of mortality (17.1% versus 27.1%, P<0.001) at 3 months. Further significant predictors of successful reperfusion were age (odds ratio, 0.98 [95% CI, 0.96-0.99]; P=0.035) and intravenous thrombolysis (odds ratio, 10.58 [95% CI, 10.04-20.4]; P=0.033). Intracranial-first approach (n=227) compared with extracranial-first approach (n=267) resulted in a shorter time to flow restoration (53.5 versus 72.0 minutes, P<0.001) and a higher nonsignificant probability of good outcome (45.8% versus 33.0%, P=0.24) without differences in periprocedural complications. Conclusions: In tandem lesions in the anterior circulation, acute treatment of the extracranial ICA lesion is associated with better clinical outcome and lower mortality. The intracranial-first approach might provide advantages.

Automated summary

This study analyzed data from the German Stroke Registry-Endovascular Treatment and found that acute treatment of the extracranial ICA lesion in tandem lesions in the anterior circulation is associated with better clinical outcomes and lower mortality. The intracranial-first approach may provide advantages in these cases.