Tandem Lesion Strokes: to stent or not to stent, Insights from a Decade of Experience at a Comprehensive Stroke Center in Argentina

BackgroundTandem lesion strokes (TLS), defined by the coexistence of an intracranial large- or medium-vessel occlusion and a concomitant cervical internal carotid artery (ICA) stenosis or occlusion, represent a challenging subtype of acute ischemic stroke. Optimal endovascular management remains controversial, particularly regarding the role of emergent carotid artery stenting (eCAS) during mechanical thrombectomy. ObjectiveTo compare the safety and efficacy of emergent carotid artery stenting versus mechanical thrombectomy alone in patients with anterior circulation tandem lesion strokes treated at a comprehensive stroke center. MethodsWe conducted a retrospective observational cohort study of consecutive adults with anterior circulation TLS treated with endovascular therapy within 24 hours of symptom onset between January 2015 and July 2025. Patients were categorized into two groups according to treatment strategy: eCAS performed during thrombectomy or mechanical thrombectomy alone (MTa). Primary efficacy outcomes were ordinal shift in 90-day modified Rankin Scale (mRS), excellent outcome (mRS 0-1), and functional independence (mRS 0-2). Secondary efficacy outcome was successful recanalization (TICI [≥]2b). Primary safety outcomes included symptomatic intracranial hemorrhage (sICH), in-hospital mortality, and 90-day mortality. ResultsA total of 111 patients were included (mean age 71.2 {+/-} 12.6 years; 68.5% male), of whom 74 (67%) underwent eCAS and 37 (33%) received MTa. Patients treated with eCAS achieved higher rates of successful recanalization (97.3% vs 78.4%; OR 13.26, 95% CI 2.13-82.49; p = .006) and excellent functional outcomes at 90 days (41.9% vs 12.5%; OR 6.80, 95% CI 1.35-34.20; p = .020). There were no significant differences between groups in rates of sICH, early neurological deterioration, or mortality. Ordinal logistic regression showed a non-significant trend toward better functional outcomes with eCAS. ConclusionsIn this single-center experience, emergent eCAS during mechanical thrombectomy for TLS was associated with higher reperfusion rates and improved functional outcomes without increased hemorrhagic risk or mortality. These findings support eCAS as a feasible and safe strategy in selected patients and highlight the need for prospective randomized trials.