Extracranial reconstruction strategies for management of acute tandem occlusion strokes: hemorrhage risks and functional outcome.

backgroundOptimal extracranial management in acute ischemic stroke due to tandem occlusions remains controversial. Balloon-expandable stents used as a bridging strategy with reduced early antiplatelet therapy have been proposed to decrease hemorrhagic risk, but comparative real-world data remain limited.

methodsWe retrospectively analyzed 268 consecutive patients with tandem occlusions treated with mechanical thrombectomy and one of three extracranial reconstruction strategies: percutaneous transluminal angioplasty (PTA, n = 63), balloon-mounted coronary stenting as bridging therapy (n = 56), or self-expanding carotid stenting (n = 149). The primary endpoint was symptomatic intracranial hemorrhage (sICH). Secondary endpoints included hemorrhagic subtypes, reperfusion metrics, re-occlusion, and 90-day functional outcome (modified Rankin Scale [mRS]).

resultsBaseline stroke severity differed among groups, with higher NIHSS scores and larger infarct core volumes in the balloon-expandable stent group (p = 0.001). Early antiplatelet therapy within 24 h also differed significantly among treatment strategies (p < 0.001). Symptomatic intracranial hemorrhage occurred in 10.1% of patients and did not differ among groups (p = 0.598). Rates of any hemorrhage (p = 0.071), hemorrhagic transformation (p = 0.377), PH1 (p = 0.651), and PH2 (p = 0.813) were comparable, although HT2 was more frequent in the balloon-expandable stent group (p = 0.018). Complete reperfusion (TICI 3) differed significantly among groups (p < 0.001). Favorable functional outcome (mRS 0-2) at 90 days was highest in the self-expanding stent group (71.1%) compared with PTA (47.6%) and balloon-expandable stenting (58.9%) (p = 0.004). However, after multivariable adjustment, favorable outcome was independently associated with younger age, lower baseline NIHSS, higher ASPECTS, and complete reperfusion, whereas extracranial treatment strategy was not independently associated with outcome. Re-occlusion rates did not differ among groups (p = 0.250).

conclusionsExtracranial reconstruction strategy was not associated with differences in symptomatic intracranial hemorrhage despite substantial variability in early antiplatelet therapy. Although favorable functional outcomes differed among treatment groups in unadjusted analyses, extracranial treatment strategy was not independently associated with outcome after multivariable adjustment. Hemorrhagic and functional outcomes in tandem occlusions appear to be driven primarily by baseline stroke severity, infarct burden, and reperfusion success, supporting an individualized approach to extracranial reconstruction.