Management of acute ischemic stroke due to tandem occlusion
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Acute tandem occlusion involving the cervical internal carotid artery (ICA) with concomitant intracranial thromboembolism to the intracranial ICA terminus or middle cerebral artery (MCA) is estimated to occur in 15% of all cases of large-vessel acute ischemic stroke.17 These lesions are challenging to manage endovascularly and respond poorly to intravenous (IV) tissue plasminogen activator (tPA).2 Tandem lesions typically have a worse prognosis than an intracranial lesion alone and are associated with higher rates of symptomatic intracranial hemorrhage (ICH), with 1 small series reporting a 22% rate of symptomatic ICH and a 39% rate of 90-day mortality.There is controversy regarding which lesion should be treated first (extracranial vs intracranial). Different endovascular approaches have been proposed, including mechanical thrombectomy without attempted treatment of the cervical ICA, angioplasty and stenting of the cervical lesion first, followed by intracranial thrombectomy, or treatment of the intracranial occlusion with mechanical thrombectomy first, followed by treatment of the cervical ICA occlusion.

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