Emergent Carotid Stenting During Thrombectomy in Tandem Occlusions Secondary to Dissection: A STOP-CAD Secondary Study

BACKGROUND: The optimal endovascular management of cervical carotid dissection causing tandem occlusion remains uncertain. We investigated the impact of emergent carotid stenting during endovascular treatment for acute ischemic stroke in patients with tandem occlusion secondary to cervical carotid artery dissection. METHODS: This was a secondary analysis of patients treated with endovascular treatment for acute ischemic stroke due to occlusive carotid artery dissection and tandem occlusion included in the retrospective international STOP-CAD study (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection). We compared patients with and without emergent stenting. The primary efficacy and safety outcomes were 90-day functional independence (modified Rankin Scale score, 0-2) and symptomatic intracranial hemorrhage within 24 hours after endovascular treatment. Procedural outcome was successful intracranial recanalization (modified Thrombolysis in Cerebral Infarction score of 2b/3). We used mixed-effects logistic regression adjusting for site, age, and National Institutes of Health Stroke Scale. In additional analyses, we used inverse probability of treatment weighting and adjusted for Alberta Stroke Program Early CT Score. RESULTS: Of the 4023 patients enrolled in STOP-CAD, 328 presented with anterior circulation acute ischemic stroke due to tandem occlusion and underwent endovascular treatment. The median age was 51 (interquartile range, 44-58) years, and 96 patients (29.3%) were female. One hundred fifty patients (45.7%) underwent emergent stenting. There was no significant association between stenting and 90-day functional independence (62.0% versus 59.7%; adjusted odds ratio, 1.23 [95% CI, 0.82-1.86]; P=0.315) or symptomatic intracranial hemorrhage (7.3% versus 7.9%; adjusted odds ratio, 0.95 [95% CI, 0.41-2.2]; P=0.913). Emergent carotid stenting was associated with successful intracranial recanalization (81.8% versus 76.6%; adjusted odds ratio, 2.62 [95% CI, 1.52-4.5]; P<0.001). Results did not meaningfully change in additional analyses. CONCLUSIONS: In patients presenting with an acute anterior circulation tandem occlusion secondary to cervical carotid artery dissection, emergent stenting was associated with a higher likelihood of successful intracranial recanalization but not improved functional outcomes or increased symptomatic intracranial hemorrhage. It remains unclear whether emergent stenting led to successful intracranial recanalization or patients with successful intracranial recanalization were more likely to be stented. Randomized trials are warranted.