The Source for Neurovascular News and Education

November 29, 2022


The findings support the safety of carotid artery stenting and antiplatelet therapy with or without prior intravenous thrombolysis.


An aggressive approach to tandem large vessel occlusions is recommended based on results of a study showing that extracranial stenting and use of antiplatelet therapy do not increase the risk for hemorrhagic transformation. The findings were published online December 14, 2018, ahead of print, in Stroke.


“The effectiveness of mechanical intracranial thrombectomy with or without tandem cervical disease is comparable,” lead author François Zhu, MD (University Hospital of Nancy, France), told Neurovascular Exchange in an email. What remains unclear, he continued, is how best to manage the extracranial lesion (either an occlusion or high-grade stenosis) in the acute phase.


“In everyday practice, emergent stenting of the extracranial carotid lesion seems to be an efficient strategy for [tandem] cervical disease, but because of [the need for] adjuvant antithrombotic therapy, this approach increases the theoretical [risk] of hemorrhagic transformation,” Zhu pointed out. However, what’s unknown is whether this increased risk is real and substantial, as well as whether hemorrhagic infarction is associated with poorer outcomes.


To find out, Zhu led the TITAN (Thrombectomy in Tandem Lesions) investigators in a pooled analysis of individual data from prospectively collected multicentric thrombectomy databases. They identified 289 consecutive patients with anterior circulation tandem large vessel occlusion strokes who underwent thrombectomy. Of these patients, 24.7% developed hemorrhagic infarction and 14.2% developed parenchymal hematoma.


Multivariable multinomial logistic regression analysis identified several independent predictors of both hemorrhagic infarction and parenchymal hematoma. In addition, a higher baseline NIHSS score and an ASPECTS < 7 were independent predictors of parenchymal hematoma.


Independent Predictors of Hemorrhagic Infarction and/or Parenchymal Hematoma


Hemorrhagic Infarction

OR (95% CI)

Parenchymal Hematoma

OR (%% CI)

P Value for Overall Effect

Intracranial Carotid Occlusion

2.10 (1.09-4.02)

2.62 (1.17-5.83)


Diabetes Mellitus

2.54 (1.13-5.72)

3.57 (1.23-10.41)


Prior Intravenous Thrombolysis

0.46 (0.24-0.86)

0.51 (0.23-1.12)


Extracranial Carotid Occlusion

0.51 (0.26-0.96)

0.58 (0.24-1.34)


5-Point Increase in Admission NIHSS

1.17 (0.89-1.52)

1.66 (1.14-2.43)



0.50 (0.23-1.08)

0.38 (0.10-1.46)



While no association was seen between hemorrhagic infarction and 90-day clinical outcome, the occurrence of parenchymal hematoma was associated with increased mortality rates (adjusted OR 2.63; 95% CI 1.05-6.59). It was not associated with 90-day mRS 0-2, however (adjusted OR 0.52; 95% CI 0.20-1.28.)


The study authors were surprised  that there was no correlation between use of antiplatelet therapy and hemorrhagic transformation during the first 24 hours of follow-up, Zhu said, but he pointed out that this is concordant with a recent report by Papanagiotou et al.


“These findings support the notion that emergent carotid stenting and antiplatelet therapy administration (at least one antiplatelet agent) in the acute phase of stroke treated by endovascular thrombectomy seems to be safe, with or without prior intravenous thrombolysis,” he noted.

“Considering the fact that carotid stenting was also a predictor of successful reperfusion, the approach [of combining] intracranial thrombectomy and extracranial carotid stenting may be the best therapeutic option for [treatment] of tandem large vessel occlusion strokes,” Zhu advised. “Similar findings were also recently reported in the STRATIS registry, with a significant better clinical outcome in the emergent stenting group.”




Zhu F, Labreuche J, Haussen DC, et al. Hemorrhagic transformation after thrombectomy for tandem occlusions: Incidence, predictors, and clinical implications. Stroke. 2018;Epub ahead of print.



  • The study was supported by Stryker.
  • Zhu reports no relevant conflicts of interest.