The Source for Neurovascular News and Education

November 29, 2022

“We were relieved to see that results from this study are consistent with our experience,” but the best treatment strategy isn’t yet known, the lead author says.



Emergent carotid artery stenting (CAS) with mechanical thrombectomy can safely be performed in patients with acute ischemic stroke caused by atherosclerotic tandem occlusions, even if they have received prior intravenous thrombolysis (IVT), recently published registry data suggest. What remains uncertain, according to the study’s lead author, is if it is the best available approach.


“There has been accumulating evidence supporting the benefit of emergent CAS in tandem occlusion,” Mohammad Anadani, MD (Medical University of South Carolina, Charleston), told Neurovascular Exchange in an email. “However, the safety of CAS after IVT is still debatable, especially since these patients require periprocedural antiplatelet therapy, which comes with its own risk after IVT. This study was conducted to answer an important but yet unanswered question regarding the safety of CAS after IVT.”


For their study, released online June 17, 2019, ahead of print in Stroke, Anadani et al analyzed data on 205 patients from the multicenter observational TITAN registry who had acute ischemic stroke caused by tandem occlusions and who were treated with emergent carotid artery stenting and mechanical thrombectomy. Of these, 125 had received prior IVT.


No Increased Hemorrhagic or Procedural Complications


Patients with and without prior IVT were similar with respect to baseline characteristics, with the exception of a shorter mean time from symptom onset to groin puncture (234 vs 256 min; P = 0.002) and less heparin use (14% vs 35%; P < 0.001) in the prior IVT group.


There was no significant difference between the IVT and no-IVT groups with respect to the rate of symptomatic intracerebral hemorrhage (ICH), parenchymal hematoma type 1 to 2, successful reperfusion (defined as an mTICI 2b-3), or 90-day favorable outcome (defined as an mRS score 0-2). The 90-day all-cause mortality rate was significantly lower in the IVT group.


Outcomes by Use of Prior IVT




(n = 125)


(n = 80)

P Value

Symptomatic ICH




Parenchymal Hematoma Type 1-2




mTICI 2b-3




90-Day Favorable Outcome




90-Day All-Cause Mortality





After adjusting for covariates, IVT was not associated with symptomatic ICH or 90-day all-cause mortality.


Anadani described his response to the findings as that of relief. “We have anecdotally encountered multiple situations where we used stent[ing] and antiplatelet therapy emergently after IVT without a significant increased risk of hemorrhage,” he explained. “We were relieved to see that results from this study are consistent with our experience.”


Do Not Defer CAS After IVT


“Despite the evidence supporting the benefit of CAS in tandem occlusion, neurointerventionalists not infrequently defer CAS after IVT due to safety concerns,” Anadani pointed out. “We believe, based on our results, that CAS should not be deferred after IVT.”


While there’s evidence of safety, he added, it remains uncertain whether CAS is the best approach to treatment in stroke patients with tandem occlusions who received IVT. There also is still a lack of consensus regarding the best periprocedural antithrombotic treatment strategy in tandem occlusions, especially after IVT.


“We want to stress that our study does not suggest an optimal treatment strategy and further studies are needed to determine if CAS is superior to other treatment options in tandem occlusion after IVT,” Anadani emphasized to NVX.



Anadani M, Spiotta AM, Alawieh A, et al. Emergent carotid stenting plus thrombectomy after thrombolysis in tandem strokes: analysis of the TITAN registry. Stroke. 2019;Epub ahead of print.




Anadani reports no relevant conflicts of interest.