Tandem Lesions in Anterior Circulation Stroke
Authors: Feil Katharina , Herzberg Moriz , Dorn Franziska , Tiedt Steffen , Küpper Clemens , Thunstedt Dennis C. , Papanagiotou Panagiotis , Meyer Lukas , Kastrup Andreas , Dimitriadis Konstantinos , Liebig Thomas , Dieterich Marianne , Kellert Lars , Boeckh-Behrens Tobias , Wunderlich Silke , Ludolph Alexander , Henn Karl-Heinz , Reich Arno , Mpotsaris Anastasios , Wiesmann Martin , Ernemann Ulrike , Poli Sven , Nolte Christian H. , Siebert Eberhard , Zweynert Sarah , Bohner Georg , Solymosi Laszlo , Petzold Gabor , Pfeilschifter Waltraud , Keil Fee , Röther Joachim , Eckert Bernd , Berrouschot Jörg , Bormann Albrecht , Alegiani Anna , Fiehler Jens , Gerloff Christian , Thomalla Götz , Thonke Sven , Bangard Christopher , Kraemer Christoffer , Dichgans Martin , Psychogios Marios , Liman Jan , Petersen Martina , Stögbauer Florian , Kraft Peter , Pham Mirko , Braun Michael , Hamann Gerhard F. , Roth Christian , Gröschel Klaus , Uphaus Timo , Limmroth Volker 
Published: February 2021

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.