Our study indicates that early recanalization with MT followed by emergent CEA is safe and feasible, which suggests that both CAS and CEA should be considered in the emergent treatment of patients with tandem occlusion.

Background: Concomitant acute cervical ICA and intracranial large vessel occlusion (ILVO) has a high rate of morbidity and mortality. The most appropriate treatment strategy for the extracranial culprit lesion remains unclear. We report our institutional outcomes with the 2 approaches, emergent carotid endartectomy (CEA) vs. stenting (CAS). Methods: Between July 2012 to April 2016, 34 patients with concomitant complete ICA origin occlusion and occlusion of either intracranial ICA, MCA M1 or M2 segments underwent thrombectomy at our center. Demographics, risk factors, treatment modalities, imaging and clinical outcomes were reviewed from a prospectively maintained database. Recanalization, hemorrhagic transformation (HT) with clinical decline of >4 points on the NIHSS and favorable outcome rates mRs of < 2 at 90 days were compared. Results: Of the 34 identified subjects, in 6 patients the proximal lesion was not treated either due to failed MT (N=3), ICA re-occlusion prior to CEA (N=2) or MCA recanalization via trans-circulation access with symptomatic resolution (N=1). Of the remaining 28 patients, 10 (35.7%) underwent emergent CEA within 12 hours following MT, while the remainder 18 (64.3%) had carotid stenting performed during the MT. Rate of IV tPA treatment was higher in CAS (61% vs 10%, p<0.01). Successful TICI 2B/3 recanalization was achieved in 90% of the CEA and 94.1% of stenting patients (p=0.6). Following CAS, 3 patients developed HT while none were noted in the CEA arm. At 90 days, 80% (8/10) of the CEA patients were functionally independent compared to 58.8% (10/18) in the stenting group, although this difference was not statistically different (p=0.3). No deaths in the CEA group were noted as compared to 4 (23.5%) in the stenting arm (p=0.09). Conclusions: Our study indicates that for concomitant cervical ICA and ILVO, MT followed by emergent CEA is feasible and may be accompanied with less risk for HT and improved rate of favorable outcome. Further prospective studies are warranted.