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

João André Sousa^#¹, Marc Rodrigo-Gisbert^#², Liqi Shu³, Anqi Luo⁴, Han Xiao⁵, Noor A Mahmoud⁶, Asghar Shah⁷, Ana Luyza Oliveira Santos⁶, Marina Moore⁸, Daniel M Mandel³, Mirjam R Heldner⁹, Vasco Barata¹, Sara Bernardo-Castro¹, Nils Henninger¹⁰, Jayachandra Muppa¹⁰, Marcel Arnold⁹, Ahmad Nehme¹¹, Aaron Rothstein¹², Ossama Khazaal¹², Josefin E Kaufmann¹³, Stefan T Engelter¹³, Christopher Traenka¹³, Issa Metanis¹⁴, Ronen R Leker¹⁴, Christian H Nolte^{15

16

17}, Malik Ghannam¹⁸, Edgar A Samaniego¹⁸, Mohammad Almajali¹⁸, Alexandre Y Poppe¹⁹, Michele Romoli²⁰, Jennifer Frontera²¹, Marialuisa Zedde²², Wayneho Kam²³, Brian Mac Grory²⁴, Faddi Saleh Velez⁶, Tamra Ranasinghe²⁵, James E Siegler²⁶, Adeel Zubair²⁷, João Pedro Marto²⁸, Piers Klein²⁹, Thanh N Nguyen²⁹, Mohamad Abdalkader²⁹, Gabriel Mantovani³⁰, Alexis N Simpkins³¹, Shayak Sen³¹, Marwa Elnazeir³², Shadi Yaghi³, Joao Sargento-Freitas¹, Manuel Requena²

Affiliations

¹ Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Unidade Local de Saúde de Coimbra, Portugal (J.A.S., V.B., S.B.-C., J.S.-F.).
² Department of Neurology, University Hospital Vall d'Hebron, Barcelona, Spain (M.R.-G., M. Requena).
³ Department of Neurology, Brown Medical School, Providence, RI (L.S., D.M.M., S.Y.).
⁴ Department of Neurology, UT Health San Antonio, TX (A.L.).
⁵ Economics Department, University of California, Santa Barbara (H.X.).
⁶ Department of Neurology, University of Oklahoma (N.A.M., A.L.O.S., F.S.V.).
⁷ Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (A.S.).
⁸ Department of Neurology, Dell Medical School, University of Texas at Austin (M.M.).
⁹ Department of Neurology, Inselspital, University of Bern, Switzerland (M.R.H., M. Arnold).
¹⁰ Department of Neurology, University of Massachusetts Chan Medical School, Worcester (N.H., J.M.).
¹¹ Service de Neurologie, CHU Caen Normandie, Université Caen Normandie, France (A.N.).
¹² Department of Neurology, University of Pennsylvania, Philadelphia (A.R., O.K.).
¹³ Department of Neurology, University Department of Geriatric Medicine FELIX PLATTER, Department of Clinical Research, University of Basel, Switzerland (J.E.K., S.T.E., C.T.).
¹⁴ Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel (I.M., R.R.L.).
¹⁵ Department of Neurology With Experimental Neurology (C.H.N.), Charite-Universitätsmedizin Berlin, Germany.
¹⁶ Center for Stroke Research Berlin (C.H.N.), Charite-Universitätsmedizin Berlin, Germany.
¹⁷ Berlin Institute of Health (C.H.N.), Charite-Universitätsmedizin Berlin, Germany.
¹⁸ Department of Neurology, University of Iowa (M.G., E.A.S., M. Almajali).
¹⁹ Department of Neurosciences, Université de Montréal, Canada (A.Y.P.).
²⁰ Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli).
²¹ Department of Neurology, NYU Langone Health (J.F.).
²² Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy (M.Z.).
²³ Department of Neurology, University of North Carolina Health Rex, Raleigh (W.K.).
²⁴ Department of Neurology, Duke University, Durham, NC (B.M.G.).
²⁵ Department of Neurology, Wake Forest Medical Center, NC (T.R.).
²⁶ Department of Neurology, Cooper University, Camden, NJ (J.E.S.).
²⁷ Department of Neurology, Yale New Haven Hospital, CT (A.Z.).
²⁸ Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (J.P.M.).
²⁹ Department of Neurology, Boston Medical Center, MA (P.K., T.N.N., M. Abdalkader).
³⁰ Department of Neurology, Hospital de Clínicas de Porto Alegre, Brazil (G.M.).
³¹ Department of Neurology, Cedars Sinai Medical Center, Los Angeles, CA (A.N.S., S.S.).
³² Department of Neurology, University of Louisville, KY (M.E.).

^# Contributed equally.

PMID: 39882629
DOI: 10.1161/STROKEAHA.124.048295

Free article

Multicenter Study

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

João André Sousa et al. Stroke. 2025 Apr.

Free article

. 2025 Apr;56(4):808-817.

doi: 10.1161/STROKEAHA.124.048295. Epub 2025 Jan 30.

Authors

Affiliations

¹ Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Unidade Local de Saúde de Coimbra, Portugal (J.A.S., V.B., S.B.-C., J.S.-F.).
² Department of Neurology, University Hospital Vall d'Hebron, Barcelona, Spain (M.R.-G., M. Requena).
³ Department of Neurology, Brown Medical School, Providence, RI (L.S., D.M.M., S.Y.).
⁴ Department of Neurology, UT Health San Antonio, TX (A.L.).
⁵ Economics Department, University of California, Santa Barbara (H.X.).
⁶ Department of Neurology, University of Oklahoma (N.A.M., A.L.O.S., F.S.V.).
⁷ Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (A.S.).
⁸ Department of Neurology, Dell Medical School, University of Texas at Austin (M.M.).
⁹ Department of Neurology, Inselspital, University of Bern, Switzerland (M.R.H., M. Arnold).
¹⁰ Department of Neurology, University of Massachusetts Chan Medical School, Worcester (N.H., J.M.).
¹¹ Service de Neurologie, CHU Caen Normandie, Université Caen Normandie, France (A.N.).
¹² Department of Neurology, University of Pennsylvania, Philadelphia (A.R., O.K.).
¹³ Department of Neurology, University Department of Geriatric Medicine FELIX PLATTER, Department of Clinical Research, University of Basel, Switzerland (J.E.K., S.T.E., C.T.).
¹⁴ Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel (I.M., R.R.L.).
¹⁵ Department of Neurology With Experimental Neurology (C.H.N.), Charite-Universitätsmedizin Berlin, Germany.
¹⁶ Center for Stroke Research Berlin (C.H.N.), Charite-Universitätsmedizin Berlin, Germany.
¹⁷ Berlin Institute of Health (C.H.N.), Charite-Universitätsmedizin Berlin, Germany.
¹⁸ Department of Neurology, University of Iowa (M.G., E.A.S., M. Almajali).
¹⁹ Department of Neurosciences, Université de Montréal, Canada (A.Y.P.).
²⁰ Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli).
²¹ Department of Neurology, NYU Langone Health (J.F.).
²² Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy (M.Z.).
²³ Department of Neurology, University of North Carolina Health Rex, Raleigh (W.K.).
²⁴ Department of Neurology, Duke University, Durham, NC (B.M.G.).
²⁵ Department of Neurology, Wake Forest Medical Center, NC (T.R.).
²⁶ Department of Neurology, Cooper University, Camden, NJ (J.E.S.).
²⁷ Department of Neurology, Yale New Haven Hospital, CT (A.Z.).
²⁸ Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (J.P.M.).
²⁹ Department of Neurology, Boston Medical Center, MA (P.K., T.N.N., M. Abdalkader).
³⁰ Department of Neurology, Hospital de Clínicas de Porto Alegre, Brazil (G.M.).
³¹ Department of Neurology, Cedars Sinai Medical Center, Los Angeles, CA (A.N.S., S.S.).
³² Department of Neurology, University of Louisville, KY (M.E.).

^# Contributed equally.

PMID: 39882629
DOI: 10.1161/STROKEAHA.124.048295

Abstract

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.

Keywords: carotid arteries; ischemic stroke; logistic models; middle aged; stents.

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Conflict of interest statement

Dr Heldner reports grants from Swiss Institute for Translational and Entrepreneurial Medicine Research Support Funds and Swiss National Science Foundation, Swiss Heart Foundation, not directly related to this article. Dr Romoli reports fees from CSL Behring and research grants from the Italian Stroke Association (ISA-AII). Dr Leker reports speaker honoraria from IschemaView, Boehringer Ingelheim, Pfizer, Jansen, Biogen, Medtronic, and Abbott; advisory board honoraria from Jansen, none related to this article; and compensation from Bayer for other services. Dr Nguyen reports advisory board membership with Idorsia and Brainomix; compensation from the American Stroke Association for other services; and compensation from Aruna for consultant services. Dr Requena reports a consulting agreement with Anaconda Biomed, not directly related to this article. Dr Arnold reports compensation from AstraZeneca, Bayer, Bristol Myers Squibb, Covidien, Daiichi Sankyo, Novartis, Sanofi, Pfizer, Amgen, Novo Nordisk, Boehringer Ingelheim, and Covidien/Medtronic for consultant services. Dr Rothstein reports grants from the American Heart Association. Dr Traenka reports grants from Gottfried und Julia Bangerter-Rhyner-Stiftung, Swiss Heart Foundation, and Freiwillige Akademische Gesellschaft and travel support from Bayer Healthcare. Dr Nolte reports compensation from Novartis, Deutsches Zentrum für Neurodegenerative Erkrankungen, Bristol Myers Squibb, AstraZeneca, Deutsches Zentrum für Herz-Kreislaufforschung for other services; and compensation from Pfizer for consultant services. Dr Samaniego reports compensation from Medtronic, MicroVention, Inc, Rapid Medical, and Johnson and Johnson for consultant services. Dr Poppe reports grants from the Canadian Institutes of Health Research, Fondation Brain Canada, Stryker, and Heart and Stroke Foundation of Canada. B. Mac Grory reports grants from the American Heart Association, Duke Bass Connections, National Institutes of Health, and Duke Office of Physician Scientist Development. Dr Siegler reports employment by Cooper Hospital; grants from Philips and viz.ai; compensation from AstraZeneca for other services; and employment by the University of Chicago. Dr Simpkins reports compensation from National Institute of Neurological Disorders and Stroke for data and safety monitoring services; compensation from Up to Date for other services; and grants from the National Institutes of Health. The other authors report no conflicts.

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

Affiliations

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

Authors

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Abstract

Conflict of interest statement

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