ESOC 2025 | The CERES-TANDEM study: emergent carotid stenting during thrombectomy in tandem lesion stroke

So first of all, tandem lesions means a simultaneous high-grade extracranial carotid stenosis or occlusion with intracranial vessel occlusion. This occurs in up to 20% of large vessel stroke, but these patients were largely excluded from major randomized thrombectomy trials. So the optimal management for the extracranial carotid segment is still unclear, has remained uncertain. And there are observational studies offering mixed signals on benefits versus hemorrhagic risk. So the CERES-TANDEM study is an investigator-led international multicenter cohort study of consecutive patients treated for anterior circulation tandem lesions between 2018 and 2024 at 49 comprehensive stroke centers across Europe, North America, and Singapore. It’s an investigator-led study led by me at the Bufalini Comprehensive Stroke Center in Italy, Cesena, by Francesco Diana at the Vall d’Hebron Research Institute in Barcelona, Spain, and by Tan Nguyen at Boston University and Boston Medical Center in the U.S. We included 4,053 patients, median age around 70 years, 65% women, of which more than 2,000 underwent emergent carotid stenting during thrombectomy, and more than 1,000 were treated with thrombectomy alone, 1,531. We used stabilized inverse probability of treatment weighting to adjust variables and known confounders between the two groups. And we then applied weighted ordinal logistic regression to compare 90-day modified Rankin scale outcomes between the two strategies. The results were pretty clear. First of all, we had an improved functional recovery with stenting, as emergent carotid stenting was associated with a 31% higher odds of a one-point shift toward a better outcome in terms of modified Rankin scale. And we had better rates of independence, so the odds of achieving a modified Rankin scale zero to one increased by 27% with stenting. We also had higher recanalization success with complete or near complete recanalization rising from 75% to 90% with stenting, and seemingly at no cost of hemorrhagic safety, as no significant increase in symptomatic intracranial hemorrhage was observed. These results were pretty much consistent. We used an estimate-based framework, so we measured the total effect, direct effect, and principal stratum, and all analyses confirmed the robustness of the benefit of stenting. We also conducted the sensitivity analysis for reversal temporal relationship between recanalization status and stenting. So, we also consider stenting impact only after including recanalization status in the waiting procedure, and this still had consistent results with a net benefit of stenting over a non-stenting approach. So overall, we can say that emergent carotid stenting, alongside thrombectomy, can be considered for tandem lesion stroke and may yield more complete recanalization and significantly improved 90-day outcomes. Crucially, even after adjusting for recanalization status, stenting remains a strong predictor of better functional outcome. So this can be considered during our clinical practice.

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