Most recent clinical trials have not evaluated the efficacy of mechanical thrombectomy in patients presenting with large vessel anterior acute ischemic stroke from tandem occlusions. The definition of tandem occlusion is severe stenosis or occlusion of the cervical internal carotid artery ipsilateral to its intracranial occlusion. The mechanism is typically cervical ICA atherosclerosis or dissection. When faced with a tandem occlusion, the interventionalist has the choice to decide from several therapeutic strategies with the most common the “proximal-to-distal”, or anterograde, approach. We present a patient that underwent this approach and brings to question the optimal approach.

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A 49-year-old man with a history of hypertension presented with global aphasia and right hemiparesis with NIHSS of 35. CTA head and neck demonstrated a left ICA and MCA tandem occlusion with mechanism secondary to left ICA dissection. The patient underwent direct aspiration first pass (ADAPT) thrombectomy for the intracranial M1 occlusion. During thrombectomy, the cervical ICA re-canalized with resulting double lumen sign supporting underlying dissection as the mechanism. Patient underwent TICI 2B recanalization of left MCA with filling of all distal cortical branches of left MCA except for a large posterior inferior M3 branch occlusion. Patient's discharge MRS was 5. He was kept on Apixaban for anticoagulation given the dissection.

The anterograde approach was performed to recanalize an intracranial occlusion secondary to thromboembolism from dissection in this case. Stent placement was deferred given patency achievement of the extracranial ICA. The decision to stent depends upon the Circle of Willis functionality, extent of the dissection, infarct volume, and the risks of hemorrhage stroke. This case sheds light upon the need for more trials to establish standardized management of the extracranial portion when its recanalization is achieved during the procedure after intracranial thrombectomy.