Extracranial Reconstruction Strategies for Management of Acute Tandem Occlusion Strokes: Hemorrhage risks and functional outcome

Extracranial Reconstruction Strategies for Management of Acute Tandem Occlusion Strokes: Hemorrhage risks and functional outcome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Extracranial Reconstruction Strategies for Management of Acute Tandem Occlusion Strokes: Hemorrhage risks and functional outcome arsida bajrami, sena aksoy, senadim songul, serdar geyik This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9354360/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Optimal extracranial management in acute ischemic stroke due to tandem occlusions remains controversial. Balloon-expandable stents used as a bridging strategy with reduced early antiplatelet therapy have been proposed to decrease hemorrhagic risk, but comparative real-world data are limited. Methods: We retrospectively analyzed 268 consecutive patients with tandem lesions treated with mechanical thrombectomy and one of three extracranial strategies: percutaneous transluminal angioplasty (PTA, n = 63), balloon-mounted coronary stenting (n = 56), or self-expanding carotid stenting (n = 149). The primary endpoint was symptomatic intracranial hemorrhage (sICH). Secondary endpoints included hemorrhagic subtypes, reperfusion metrics, re-occlusion, and 90-day functional outcome (mRS). Results: Baseline stroke severity differed among groups, with higher NIHSS scores and larger core volumes in the coronary stent group (p = 0.001). Early antiplatelet therapy within 24 hours also differed significantly (p < 0.001). sICH occurred in 10.1% and did not differ among groups (p = 0.598). Rates of any hemorrhage (p = 0.071), hemorrhagic transformation (p = 0.377), PH1 (p = 0.651), and PH2 (p = 0.813) were comparable, although HT2 was more frequent in the coronary group (p = 0.018). Final TICI grades differed significantly (p < 0.001). Favorable functional outcome (mRS 0–2) at 90 days was highest in the self-expanding stent group (71.1%) compared with PTA (47.6%) and coronary stenting (58.9%) (p = 0.004). However, in multivariable analysis, favorable outcome was independently associated with younger age, lower NIHSS, higher ASPECTS, and complete reperfusion, while extracranial strategy was not independently associated. Re-occlusion rates did not differ (p = 0.250). Conclusions: Extracranial device selection was not associated with differences in symptomatic intracranial hemorrhage despite substantial variability in antiplatelet therapy. Self-expanding stenting was associated with superior functional outcome without increased bleeding risk, supporting individualized management strategies. Figures Figure 1 INTRODUCTION Acute ischemic stroke due to tandem lesions—defined as the coexistence of an extracranial internal carotid artery (ICA) lesion and an intracranial large-vessel occlusion—represents a particularly complex subset of patients undergoing endovascular therapy ( 1 – 3 ) . Although mechanical thrombectomy has become the standard of care for large-vessel occlusion ( 4 – 9 ) , patients with tandem occlusions were largely excluded from the pivotal randomized trials, leaving the optimal strategy for management of the extracranial ICA lesion unresolved. Acute carotid stenting enables immediate restoration of extracranial flow and may facilitate intracranial reperfusion ( 1 – 3 ) . However, it generally requires early antiplatelet therapy, raising concerns regarding hemorrhagic transformation—especially in patients with large infarct cores, low ASPECTS, or prior intravenous thrombolysis ( 9 – 11 ) . The cumulative hemorrhagic risk in this setting may be further influenced by reperfusion injury, blood–brain barrier disruption, and pharmacologic interactions between thrombolytic and antiplatelet agents. Endovascular options for managing the extracranial component of tandem lesions remain heterogeneous ( 12 – 14 ) . Balloon angioplasty alone avoids mandatory dual-antiplatelet therapy but has been associated with higher rates of acute recoil or re-occlusion. Conventional self-expanding carotid stents provide durable scaffolding but require early dual-antiplatelet therapy. More recently, a “bridging” strategy using balloon-expandable stents has been proposed as a temporary flow-restoration technique aimed at minimizing early antiplatelet intensity while maintaining vessel patency ( 15 ) . Despite growing interest in these approaches, comparative real-world data evaluating hemorrhagic safety and functional outcomes across different extracranial strategies remain limited. The present study aimed to compare three extracranial management strategies—percutaneous transluminal angioplasty, bridging therapy with balloon-mounted coronary stent, and self-expanding carotid stenting—in a real-world cohort of patients with tandem occlusions, focusing on hemorrhagic complications and functional outcomes. METHODS Study Design We conducted a single-center, retrospective observational study by review of our prospected collected database for acute ischemic stroke. Consecutive patients aged ≥ 18 years, with confirmed tandem occlusion (stenosis ≥90% or occlusion of extracranial ICA origin associated with large-vessel occlusion in the anterior circulation) on CT or MR angiography who underwent EVT were included. Patients with extracranial ICA occlusion (regardless of underlying etiology) distal to the cervical segment were not included in the study population due to ineligibility to apply the bridging therapy protocol. Additionally, patients with isolated intracranial occlusions, posterior circulation strokes, or incomplete clinical or imaging data were excluded. Institutional ethical committee approved the study protocol. Study Population: Patient demographic data, past medical history with defined risk factors and previous modified Rankin Scale score ( 16 ) , and neurological symptoms assessed by the National Institutes of Health Stroke Scale (NIHSS) ( 17 ) were recorded. Baseline imaging consisted of non-contrast CT or diffusion-weighted MRI with vascular imaging. ASPECTS ( 18 ) was assessed on baseline imaging. Perfusion imaging parameters, including infarct core and mismatch volumes, were recorded when available. Hemorrhagic transformation was classified according to Heidelberg classification ( 19 ) . Symptomatic intracranial hemorrhage was defined according to ECASS ( 20 ) criteria as any intracranial hemorrhage associated with neurological deterioration of ≥ 4 NIHSS points attributable to hemorrhage. Time metrics including onset to door, door to imaging, groin to puncture and recanalization times were recorded. Endovascular Procedure and Extracranial Treatment Endovascular treatment protocol was crossing the severe stenotic or occluded ICA origin, followed by mechanical thrombectomy to the intracranial LVO and completion of the procedure with management of extracranial ICA pathology. The first two parts of the procedures were similar in all population. All procedures were performed from femoral approach with use a 6F-90cm long sheath. In most cases, lesions were passed using a combination of 0.14mm wire and PTA balloon. In a group of patients where this method was unsuccessful, a combination of 0.35mm hydrophilic wire and 5F conventional diagnostic catheter was used. Mechanical thrombectomy was performed using aspiration, stent retriever, or combined techniques at the discretion of the treating neurointerventionalist. Acute extracranial ICA management was categorized as: percutaneous transluminal angioplasty (PTA) alone, bridging therapy with balloon-mounted coronary stents ( 15 ) and regular self-expanding carotid stent implantation ( 21 – 23 ) . The degree of reperfusion after each pass and at the end of the procedure was graded according to the mTICI scale. The bridging technique with balloon-mounted stenting was published by Rodríguez-Villatoro et al ( 15 ) . to maintain carotid patency in tandem occlusions while minimizing early antiplatelet exposure. The short length and lower metal load of balloon-expandable coronary stents allow focal plaque stabilization and flow restoration with limited thrombogenic surface. A self-expanding carotid stent is subsequently deployed—typically after ~ 48 hours and before discharge—within the balloon-mounted stent to provide durable scaffolding and prevent long-term compression. Antiplatelet Treatment Antiplatelet regimen options were as follows: a) no antiplatelet medication within first 24-hour; b) overnight infusion of iv tirofiban which then followed by oral DAPT; c)1mg iv tirofiban followed by oral administration of clopidogrel + ASA or ticagrelor + ASA immediately after the procedure. Outcome Measures The primary outcome was symptomatic intracranial hemorrhage. Secondary outcomes included any intracranial hemorrhage, reperfusion success (TICI), 24-hour NIHSS, 90-day modified Rankin Scale (mRS), and follow-up extracranial ICA patency. Statistical Analysis Statistical analyses were performed using SPSS version 27. Continuous variables were expressed as mean ± SD or median (min–max) and compared using appropriate parametric or non-parametric tests. Categorical variables were compared using chi-square or Fisher’s exact tests. A p-value < 0.05 was considered statistically significant. RESULTS Study Population A total of 268 consecutive patients with acute ischemic stroke due to tandem lesions were included (Table 1 ). The mean age was 66.3 ± 10.4 years (median 66; range 44–93), and 190 patients (70.9%) were male. Vascular risk factors included hypertension in 76.9%, diabetes mellitus in 34.0%, hyperlipidemia in 79.9%, and coronary artery disease in 29.5%. Atrial fibrillation was present in 12.3% of patients. Table 1 Baseline clinical and imaging characteristics Variable PTA Coronary stent Self-expanding stent p-value Age 68.7 ± 10.5 65.5 ± 10.1 65.6 ± 10.4 0.111 Baseline NIHSS 15.2 ± 5.6 17.1 ± 4.3 13.5 ± 6.2 0.000 Baseline ASPECTS 7.4 ± 1.9 6.1 ± 2.0 7.9 ± 1.4 0.000 Core volume (mL) 60.9 ± 50.8 71.0 ± 51.2 66.6 ± 51.1 0.688 Male sex 54.8% 71.4% 77.3% 0.005 Hypertension 83.9% 83.9% 71.3% 0.053 Diabetes mellitus 38.7% 41.1% 29.3% 0.190 Hyperlipidemia 82.3% 82.1% 78.0% 0.696 Coronary artery disease 35.5% 26.8% 28.0% 0.490 Atrial fibrillation 19.4% 5.4% 12.0% 0.068 Continuous variables are presented as mean ± SD and compared using one-way ANOVA. Categorical variables are presented as percentages and compared using χ² test. Regarding extracranial treatment strategy, 63 patients (23.5%) underwent percutaneous transluminal angioplasty (PTA), 56 patients (20.9%) received balloon-expandable stents as bridging therapy, and 149 patients (55.6%) were treated with self-expanding carotid stents. Baseline Clinical and Imaging Characteristics At admission, the median NIHSS score was 14 (IQR 0–25), and the median ASPECTS was 7 (IQR 1–10). Imaging characteristics are given in Table 2 . Baseline perfusion imaging was available in 66.4% of patients. The median ischemic core volume (ADC < 620 µm²/s) was 21 mL, with a median mismatch ratio of 3. Intracranial occlusions most frequently involved the M1 segment (52.2%), followed by the ICA terminus (25.0%) and M2 segment (20.5%). Table 2 Procedural and early imaging characteristics Variable PTA (n = 63) Balloon-expandable stent (n = 56) Self-expanding stent (n = 149) p-value Baseline NIHSS, median (IQR) 16 (11–20) 18 (15–20) 14 (8–18) 0.001 Baseline ASPECTS, median (IQR) 8 (6–9) 7 (5–7) 8 (7–9) 0.000 Intracranial occlusion M1 33/62 (53.2%) 26/56 (46.4%) 79/150 (52.7%) 0.693 Intracranial occlusion ICA 18/62 (29.0%) 19/56 (33.9%) 31/150 (20.7%) 0.113 Intracranial occlusion M2 10/62 (16.1%) 9/56 (16.1%) 37/150 (24.7%) 0.231 First-pass reperfusion (TICI ≥2B) 44/62 (71.0%) 46/56 (82.1%) 131/150 (87.3%) 0.017 Final reperfusion (TICI ≥2B) 56/62 (90.3%) 54/56 (96.4%) 150/150 (100.0%) 0.001 24-hour NIHSS, median (IQR) 10 (4–16) 10 (4–16) 6 (2–12) 0.002 24-hour ASPECTS, median (IQR) 6 (5–8) 6 (4–7) 7 (6–8) 0.000 Values are presented as n/N (%) for categorical variables and as median (IQR) for continuous variables. Between-group comparisons were performed using χ² test for categorical variables and Kruskal–Wallis test for continuous variables. Initial imaging modality did not differ significantly among treatment groups (p > 0.05). However, baseline stroke severity differed significantly across groups. Patients treated with coronary stents had higher baseline NIHSS scores compared with those treated with self-expanding stents (p = 0.001). Baseline ASPECTS also differed significantly among groups (p = 0.001), with lower ASPECTS values observed in the coronary stent group compared with both PTA and self-expanding stent groups (both p = 0.001). The proportion of patients undergoing baseline perfusion-weighted imaging did not differ significantly between groups (p > 0.05). However, ischemic core volume differed significantly (p = 0.001), with larger core volumes observed in the coronary stent group compared with the self-expanding stent group. Mismatch ratio also differed among groups (p = 0.040), with higher mismatch ratios in the self-expanding stent group compared with the coronary stent group (p = 0.024). Medical Treatment and Endovascular Therapy Intravenous thrombolysis was administered in 24 patients (9.0%). Median time from symptom onset to hospital arrival was 248 minutes, door-to-puncture time was 42 minutes, and puncture-to-recanalization time was 41 minutes. First-pass reperfusion differed significantly among extracranial treatment strategies (p = 0.033). Final successful recanalization (TICI ≥ 2b) was achieved in 96% of patients overall. Complete reperfusion (TICI 3) was achieved in 46.3% of patients and differed significantly among groups (p < 0.001), with lower rates observed in the PTA group compared with stent-treated patients. A multivariable logistic regression analysis was performed to identify independent predictors of favorable functional outcome (mRS 0–2) and intracranial hemorrhage (Table 3 ). No independent predictors of symptomatic intracranial hemorrhage were identified. After adjustment for age, baseline NIHSS, ASPECTS, final TICI grade, and extracranial treatment strategy (Fig. 1 ), independent predictors of favorable outcome included younger age (OR 0.95, 95% CI 0.92–0.98, p < 0.001), lower baseline NIHSS (OR 0.91, 95% CI 0.86–0.97, p = 0.002), higher ASPECTS (OR 1.35, 95% CI 1.13–1.61, p = 0.001), and achievement of complete reperfusion (TICI 3) (OR 1.93, 95% CI 1.08–3.46, p = 0.026). Extracranial treatment strategy was not independently associated with favorable functional outcome or intracranial hemorrhage. Table 3 Early (first 24-hour) antithrombotic treatment according to extracranial strategy Early treatment type (among treated patients) Variable PTA (n = 63) Balloon-expandable (n = 56) Self-expanding (n = 149) p No antiplatelet 41 (67.2%) 40 (71.4%) 7 (4.7%) 0.001 Any antiplatelet 20 (32.8%) 16 (28.6%) 142 (95.3%) Treatment type PTA Balloon-expandable Self-expanding p GP IIb/IIIa (Aggrastat) 7 (35%) 3 (18.8%) 75 (53.6%) 0.001 Clopidogrel 0 (0%) 2 (12.5%) 25 (17.1%) ASA + Clopidogrel 2 (10%) 1 (6.3%) 27 (18.6%) ASA 7 (35%) 8 (50%) 1 (0.7%) Ticagrelor + ASA 2 (10%) 0 (0%) 11 (7.9%) Other 2 (10%) 2 (12.5%) 3 (2.1%) Values are presented as n (%). Comparisons were performed using χ² tests. Periprocedural and Early Antiplatelet Therapy Antiplatelet therapy within the first 24 hours was administered in 67.4% of patients (Table 4 ). Early antiplatelet use differed significantly between treatment strategies (p < 0.001). Patients treated with self-expanding stents were more likely to receive early antiplatelet therapy (95.3%) compared with PTA (32.8%) and coronary stent (28.6%) groups. Table 4 Hemorrhagic outcomes according to extracranial treatment strategy Outcome PTA (n = 63) Balloon-expandable (n = 56) Self-expanding (n = 149) p Any hemorrhage 30/61 (49.2%) 32/56 (57.1%) 59/149 (39.6%) 0.064 sICH 7/61 (11.5%) 7/56 (12.5%) 13/149 (8.7%) 0.674 HT1 12/61 (19.7%) 11/56 (19.6%) 30/149 (20.1%) 0.995 HT2 8/61 (13.1%) 10/56 (17.9%) 8/149 (5.4%) 0.017 PH1 2/61 (3.3%) 4/56 (7.1%) 8/149 (5.4%) 0.643 PH2 4/61 (6.6%) 3/56 (5.4%) 8/149 (5.4%) 0.939 SAH 7/61 (11.5%) 6/56 (10.7%) 10/149 (6.7%) 0.443 Values are presented as n/N (%). Comparisons performed using χ² test. Among patients receiving early therapy, glycoprotein IIb/IIIa inhibitors (primarily tirofiban) were the most frequently used agents, particularly in the self-expanding stent group (53.6%). Dual-antiplatelet therapy was more commonly prescribed at discharge following stent implantation. Safety Outcomes Any intracranial hemorrhage (Table 5 ) occurred in 121 patients (45.1%), while symptomatic intracranial hemorrhage (sICH) occurred in 27 patients (10.1%). Rates of any hemorrhage and sICH did not differ significantly between extracranial treatment strategies (p = 0.071 and p = 0.598, respectively). Table 5 Functional and imaging outcomes according to extracranial strategy Outcome PTA (n = 63) Balloon-expandable (n = 56) Self-expanding (n = 149) p Favorable outcome (mRS 0–2) 30/62 (48.4%) 33/56 (58.9%) 106/150 (70.7%) 0.007 Mortality (mRS 6) 17/62 (27.4%) 8/56 (14.3%) 23/150 (15.3%) 0.082 Re-occlusion on follow-up 6/62 (9.7%) 10/56 (17.9%) 16/150 (10.7%) 0.302 Values are presented as n/N (%). Comparisons performed using χ² test. Hemorrhage subtype analysis revealed a significant difference in HT2 rates (p = 0.018), with higher HT2 frequency in the coronary stent group compared with the self-expanding stent group. No significant differences were observed for SAH, HT1, PH1, or PH2 across groups. Functional and Imaging Outcomes At 90 days (Table 6 ), favorable functional outcome (mRS 0–2) was achieved in 169 patients (63.1%). Functional outcomes differed significantly according to extracranial treatment strategy (p = 0.004), with the highest rate of favorable outcome observed in the self-expanding stent group (71.1%), compared with the PTA (47.6%) and coronary stent (58.9%) groups. Table 6 Multivariable logistic regression for favorable outcome (mRS 0–2) Variable OR 95% CI low 95% CI high p PTA vs Self-expanding 0.581 0.291 1.16 0.124 Balloon-expandable vs Self-expanding 1.115 0.524 2.375 0.777 Age 0.949 0.923 0.976 0.0 Baseline NIHSS 0.914 0.864 0.968 0.002 Baseline ASPECTS 1.346 1.127 1.607 0.001 Final TICI 3 1.933 1.08 3.457 0.026 Follow-up imaging demonstrated persistent or recurrent occlusion in 11.2% of patients, with no significant difference among treatment strategies (p = 0.250). DISCUSSION In this real-world cohort of patients with tandem occlusions undergoing thrombectomy, extracranial management strategy was not associated with differences in symptomatic intracranial hemorrhage despite substantial variability in early antiplatelet therapy. These findings suggest that hemorrhagic risk in tandem occlusion management is multifactorial and not determined by device selection alone. Management of tandem occlusions nevertheless remains challenging because these patients were largely excluded from the pivotal thrombectomy trials, leaving the optimal treatment of the extracranial lesion unresolved ( 1 – 5 ) . Achieving carotid patency while minimizing hemorrhagic transformation creates a therapeutic dilemma, particularly in patients with large infarct cores or low ASPECTS, in whom reperfusion injury and early antithrombotic exposure may increase bleeding risk ( 9 – 11 ) . Among various strategies for management of tandem occlusions ( 24 ) , balloon-expandable stents used as a bridging strategy with delayed or less intensive antiplatelet therapy have been proposed as a potential solution, with early single-center data suggesting reduced rates of symptomatic intracranial hemorrhage ( 15 ) . We compared three acute extracranial management strategies—percutaneous transluminal angioplasty, balloon-mounted coronary stenting, and self-expanding carotid stenting—with a primary focus on hemorrhagic complications and clinical outcomes. Despite substantial differences in baseline infarct burden and early antiplatelet therapy across treatment groups, symptomatic intracranial hemorrhage did not differ among strategies (p = 0.598). Similarly, no statistically significant differences were observed in overall hemorrhage (p = 0.071), hemorrhagic transformation (p = 0.377), PH1 (p = 0.651), or PH2 (p = 0.813). These findings suggest that extracranial device selection alone may not be a major determinant of hemorrhagic complications in tandem occlusion management. The bridging strategy was developed on the premise that a short balloon-expandable coronary stent with relatively low metal load may provide focal plaque stabilization and maintain carotid patency while allowing avoidance or delay of early antiplatelet therapy during the hyperacute phase. Although early report suggested a potential safety advantage with this strategy ( 15 ) , we did not observe a reduction in symptomatic intracranial hemorrhage or other major hemorrhagic endpoints compared with angioplasty or conventional self-expanding carotid stenting. In our cohort, baseline NIHSS (p = 0.001), ASPECTS (p = 0.001), and infarct core volume (p = 0.001) differed significantly among treatment groups, with a less favorable ischemic profile in the coronary stent group. Despite this imbalance, symptomatic hemorrhage rates were not increased. Although HT2 was more frequent in the coronary stent group (p = 0.018), this radiological difference did not translate into higher symptomatic hemorrhage or worse functional outcomes. Another important observation is that early antithrombotic strategies differed significantly among treatment groups (p = 0.001), yet this variability was not associated with higher rates of symptomatic intracranial hemorrhage (p = 0.598). Early re-occlusion rates on follow-up imaging were also similar across strategies (p = 0.250). These findings are consistent with pooled registry analyses such as the TITAN collaboration, which likewise did not demonstrate a clear association between early antiplatelet therapy during endovascular treatment and long-term favorable outcomes in tandem occlusions ( 25 , 26 ) . Together, these data suggest that early antiplatelet intensity alone may not be the primary determinant of clinically meaningful hemorrhagic complications in this setting. In unadjusted analyses, self-expanding carotid stenting was associated with higher rates of favorable functional outcome (mRS 0–2, p = 0.004), accompanied by differences in procedural and early post-procedural parameters, including final reperfusion grades (TICI, p = 0.001), 24-hour ASPECTS (p = 0.001), and 24-hour NIHSS (p = 0.001). However, after multivariable adjustment, favorable outcome was independently determined by age, baseline neurological deficit, infarct burden, and successful reperfusion, while extracranial treatment strategy—including direct comparison between self-expanding and balloon-expandable stents—was not independently associated. These findings suggest that observed functional differences across treatment strategies likely reflect baseline case selection and reperfusion success rather than intrinsic device-related effects. Evidence guiding extracranial management in tandem occlusions remains limited and is largely derived from retrospective analyses and registry data. Large pooled studies, including the TITAN ( 25 , 26 ) and ETIS collaborations ( 27 ) , have reported heterogeneous results regarding the impact of periprocedural antiplatelet therapy and extracranial stenting strategies on clinical outcomes and safety. In this context, our findings suggest that device selection alone should not be assumed to confer a hemorrhagic or functional advantage. Instead, treatment decisions should be individualized based on infarct burden, procedural considerations, and the anticipated need for durable carotid reconstruction. Although our findings did not demonstrate a reduction in symptomatic intracranial hemorrhage with balloon-expandable bridging therapy, this does not preclude its potential value in selected clinical scenarios. In practice, situations such as large infarct cores, low ASPECTS, recent intravenous thrombolysis, or perceived high hemorrhagic risk may reasonably lead operators to favor a strategy that allows delayed initiation of antiplatelet therapy. In such contexts, balloon-expandable stenting may serve as a targeted strategy rather than a default approach for all tandem occlusions. Taken together, our findings suggest that extracranial device selection alone does not determine hemorrhagic risk or functional outcome in patients with tandem occlusions undergoing thrombectomy. Instead, outcomes appear to be primarily driven by baseline infarct burden, neurological severity, and successful reperfusion. While balloon-expandable stenting may represent a pragmatic option in selected patients in whom early antiplatelet therapy is undesirable, our data do not support routine use of this strategy solely for presumed hemorrhagic protection. Future prospective studies are needed to better define patient subgroups that may benefit from tailored extracranial management strategies. Limitations This study has limitations inherent to its retrospective single-center design, and treatment allocation was based on operator judgment rather than randomization. As a result, baseline clinical and imaging characteristics differed among groups, reflecting real-world practice. Antiplatelet strategies were not protocolized and varied according to clinical context. Although multivariable analysis was performed to account for major prognostic factors, unmeasured influences related to treatment selection cannot be entirely excluded. In addition, follow-up assessment of carotid patency was based on available imaging rather than a standardized surveillance schedule. Nevertheless, the consecutive cohort, detailed imaging characterization, and comparative evaluation of three commonly used extracranial strategies provide relevant insights into contemporary management of tandem occlusions. Conclusion In this large real-world cohort of patients with tandem occlusions, extracranial management strategy was not associated with differences in symptomatic intracranial hemorrhage despite substantial variability in early antiplatelet therapy. Although unadjusted analyses suggested differences in functional outcomes across treatment strategies, these associations were no longer significant after multivariable adjustment, with recovery primarily determined by baseline neurological status, infarct burden, and successful reperfusion. These findings indicate that hemorrhagic and functional outcomes in tandem occlusions are multifactorial and not determined by device selection alone. Accordingly, extracranial reconstruction should be individualized, integrating patient characteristics, procedural considerations, and long-term vascular objectives. Declarations Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors. Competing interests The authors declare that they have no competing interests. Ethics approval Study was conducted according to Declaration of Helsinki. This study was approved by the Institutional Review Board of Istanbul Aydin University with document number of 2023/140.The requirement for informed consent was waived due to the retrospective nature of the study. Patient consent for publication Not applicable. Data availability statement Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request. Author contributions SG and AB conceived the study and supervised the project. [SS and AB] collected the data. [SA] performed statistical analysis. SG and [AB] drafted the manuscript. All authors reviewed and approved the final manuscript. Acknowledgments The authors thank the stroke and neurointerventional teams involved in patient care and data collection. References Malhotra K, Goyal N, Tsivgoulis G, et al. Endovascular treatment of tandem occlusions in acute ischemic stroke. Stroke. 2019;50:3487–93. Wilson MP, Murad MH, Krings T, et al. Management of tandem occlusions in acute ischemic stroke. Stroke. 2018;49:211–7. Papanagiotou P, Haussen DC, Turjman F, et al. Carotid stenting and mechanical thrombectomy in tandem occlusions. Stroke. 2018;49:2380–4. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. Goyal M, Demchuk AM, Menon BK, et al. 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Emergency cervical carotid artery stenting in combination with thrombectomy. AJNR Am J Neuroradiol. 2014;35:741–6. Behme D, Mpotsaris A, Zeyen P, et al. Emergency stenting of the extracranial carotid artery during thrombectomy. AJNR Am J Neuroradiol. 2015;36:2130–5. Gory B, Haussen DC, Piotin M, et al. Impact of extracranial carotid lesion treatment on outcome in tandem occlusion stroke. Stroke. 2018;49:2384–91. Liebeskind DS, Flint AC, Budzik RF, et al. Carotid revascularization strategies in tandem occlusion stroke. Stroke. 2020;51:2277–85. Anadani M, Spiotta AM, Alawieh A, et al. Emergent Carotid Stenting Plus Thrombectomy After Thrombolysis in Tandem Stroke: Analysis of the TITAN Registry. Stroke. 2019;50(8):2250–2. Anadani M, Alawieh A, Jabbour P, et al. Impact of Cervical Carotid Stenting in Tandem Occlusion Strokes Treated with Thrombectomy: Insights from the TITAN Collaboration. Stroke. 2021;52(1):e5–7. Sadeh-Gonik U, Gory B, Consoli A, et al. Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Stroke Treated with Thrombectomy: Results from the ETIS Registry. Eur J Neurol. 2018;25(4):610–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 10 May, 2026 Reviews received at journal 07 May, 2026 Reviewers agreed at journal 15 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviewers invited by journal 13 Apr, 2026 Editor assigned by journal 13 Apr, 2026 Editor invited by journal 13 Apr, 2026 Submission checks completed at journal 13 Apr, 2026 First submitted to journal 13 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9354360","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":624824592,"identity":"773ce963-b397-46d5-9f3a-b95cf797fe92","order_by":0,"name":"arsida bajrami","email":"","orcid":"","institution":"Istanbul Aydın University","correspondingAuthor":false,"prefix":"","firstName":"arsida","middleName":"","lastName":"bajrami","suffix":""},{"id":624824593,"identity":"21f8f9c8-676d-45b6-8ffa-04c51d6adc33","order_by":1,"name":"sena aksoy","email":"","orcid":"","institution":"Istanbul Aydın University","correspondingAuthor":false,"prefix":"","firstName":"sena","middleName":"","lastName":"aksoy","suffix":""},{"id":624824594,"identity":"c71facd0-aaca-46a1-a732-26648d693418","order_by":2,"name":"senadim songul","email":"","orcid":"","institution":"Istanbul Aydın University","correspondingAuthor":false,"prefix":"","firstName":"senadim","middleName":"","lastName":"songul","suffix":""},{"id":624824595,"identity":"b0ecfd91-a96c-4a2b-9d1c-049771ac0cb2","order_by":3,"name":"serdar geyik","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYDCCAyCCDYjZe8B8Hj7itfCcAXN42IjXIpED4RDUwnf7+MPHFWV2+fKRbw8+/phjJ8PGwPzw0Q08WiTP5RgbnjmXbLnxdl6ywcFtyUCHsRkb5+DRYnCGh02ysY3ZwHB2jpnEwW3MQC08bNL4tbA//9nYVm9gOPMMSEs9MVoYzBgb2w4byEvwgLQcJqxF8gyPsWTDueMGBjw5xgZntx3nYWMm4Be+M+wPPzaUVRvIt58xfFC5rdqen7354WN8WhAuPABjMROjHATkG4hVOQpGwSgYBSMOAAB1ZkZRV0zMTAAAAABJRU5ErkJggg==","orcid":"","institution":"Istanbul Aydın University","correspondingAuthor":true,"prefix":"","firstName":"serdar","middleName":"","lastName":"geyik","suffix":""}],"badges":[],"createdAt":"2026-04-08 09:22:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9354360/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9354360/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107448889,"identity":"5a924163-c810-4528-b581-e77d0a569ecc","added_by":"auto","created_at":"2026-04-21 15:00:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73437,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot showing odds ratios with 95% confidence intervals from multivariable logistic regression analysis evaluating factors associated with favorable functional outcome (modified Rankin Scale 0–2 at 90 days). The model included extracranial treatment strategy (PTA and balloon-expandable stent with self-expanding stent as reference), age, baseline NIHSS, baseline ASPECTS, and final complete reperfusion (TICI 3). Vertical reference line indicates odds ratio of 1.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9354360/v1/1ae9852cab9d06f1166ddfd3.png"},{"id":107489313,"identity":"04bd4844-c4c2-4168-92d5-02ec88b3e4cb","added_by":"auto","created_at":"2026-04-22 02:47:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":546936,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9354360/v1/aa503928-572b-4231-8653-4eccad6f717b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Extracranial Reconstruction Strategies for Management of Acute Tandem Occlusion Strokes: Hemorrhage risks and functional outcome","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAcute ischemic stroke due to tandem lesions\u0026mdash;defined as the coexistence of an extracranial internal carotid artery (ICA) lesion and an intracranial large-vessel occlusion\u0026mdash;represents a particularly complex subset of patients undergoing endovascular therapy \u003csup\u003e(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e. Although mechanical thrombectomy has become the standard of care for large-vessel occlusion \u003csup\u003e(\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e, patients with tandem occlusions were largely excluded from the pivotal randomized trials, leaving the optimal strategy for management of the extracranial ICA lesion unresolved.\u003c/p\u003e \u003cp\u003eAcute carotid stenting enables immediate restoration of extracranial flow and may facilitate intracranial reperfusion \u003csup\u003e(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e. However, it generally requires early antiplatelet therapy, raising concerns regarding hemorrhagic transformation\u0026mdash;especially in patients with large infarct cores, low ASPECTS, or prior intravenous thrombolysis \u003csup\u003e(\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e. The cumulative hemorrhagic risk in this setting may be further influenced by reperfusion injury, blood\u0026ndash;brain barrier disruption, and pharmacologic interactions between thrombolytic and antiplatelet agents.\u003c/p\u003e \u003cp\u003eEndovascular options for managing the extracranial component of tandem lesions remain heterogeneous\u003csup\u003e(\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e. Balloon angioplasty alone avoids mandatory dual-antiplatelet therapy but has been associated with higher rates of acute recoil or re-occlusion. Conventional self-expanding carotid stents provide durable scaffolding but require early dual-antiplatelet therapy. More recently, a \u0026ldquo;bridging\u0026rdquo; strategy using balloon-expandable stents has been proposed as a temporary flow-restoration technique aimed at minimizing early antiplatelet intensity while maintaining vessel patency \u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite growing interest in these approaches, comparative real-world data evaluating hemorrhagic safety and functional outcomes across different extracranial strategies remain limited. The present study aimed to compare three extracranial management strategies\u0026mdash;percutaneous transluminal angioplasty, bridging therapy with balloon-mounted coronary stent, and self-expanding carotid stenting\u0026mdash;in a real-world cohort of patients with tandem occlusions, focusing on hemorrhagic complications and functional outcomes.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eWe conducted a single-center, retrospective observational study by review of our prospected collected database for acute ischemic stroke. Consecutive patients aged \u0026ge; 18 years, with confirmed tandem occlusion (stenosis \u0026ge;90% or occlusion of extracranial ICA origin associated with large-vessel occlusion in the anterior circulation) on CT or MR angiography who underwent EVT were included. Patients with extracranial ICA occlusion (regardless of underlying etiology) distal to the cervical segment were not included in the study population due to ineligibility to apply the bridging therapy protocol. Additionally, patients with isolated intracranial occlusions, posterior circulation strokes, or incomplete clinical or imaging data were excluded. Institutional ethical committee approved the study protocol.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population:\u003c/h3\u003e\n\u003cp\u003ePatient demographic data, past medical history with defined risk factors and previous modified Rankin Scale score \u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e, and neurological symptoms assessed by the National Institutes of Health Stroke Scale (NIHSS) \u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e were recorded. Baseline imaging consisted of non-contrast CT or diffusion-weighted MRI with vascular imaging. ASPECTS \u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e was assessed on baseline imaging. Perfusion imaging parameters, including infarct core and mismatch volumes, were recorded when available. Hemorrhagic transformation was classified according to Heidelberg classification \u003csup\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e. Symptomatic intracranial hemorrhage was defined according to ECASS \u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e criteria as any intracranial hemorrhage associated with neurological deterioration of \u0026ge;\u0026thinsp;4 NIHSS points attributable to hemorrhage. Time metrics including onset to door, door to imaging, groin to puncture and recanalization times were recorded.\u003c/p\u003e\n\u003ch3\u003eEndovascular Procedure and Extracranial Treatment\u003c/h3\u003e\n\u003cp\u003eEndovascular treatment protocol was crossing the severe stenotic or occluded ICA origin, followed by mechanical thrombectomy to the intracranial LVO and completion of the procedure with management of extracranial ICA pathology. The first two parts of the procedures were similar in all population. All procedures were performed from femoral approach with use a 6F-90cm long sheath. In most cases, lesions were passed using a combination of 0.14mm wire and PTA balloon. In a group of patients where this method was unsuccessful, a combination of 0.35mm hydrophilic wire and 5F conventional diagnostic catheter was used. Mechanical thrombectomy was performed using aspiration, stent retriever, or combined techniques at the discretion of the treating neurointerventionalist. Acute extracranial ICA management was categorized as: percutaneous transluminal angioplasty (PTA) alone, bridging therapy with balloon-mounted coronary stents\u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e and regular self-expanding carotid stent implantation\u003csup\u003e(\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/sup\u003e. The degree of reperfusion after each pass and at the end of the procedure was graded according to the mTICI scale.\u003c/p\u003e \u003cp\u003eThe bridging technique with balloon-mounted stenting was published by Rodr\u0026iacute;guez-Villatoro et al \u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e. to maintain carotid patency in tandem occlusions while minimizing early antiplatelet exposure. The short length and lower metal load of balloon-expandable coronary stents allow focal plaque stabilization and flow restoration with limited thrombogenic surface. A self-expanding carotid stent is subsequently deployed\u0026mdash;typically after ~\u0026thinsp;48 hours and before discharge\u0026mdash;within the balloon-mounted stent to provide durable scaffolding and prevent long-term compression.\u003c/p\u003e\n\u003ch3\u003eAntiplatelet Treatment\u003c/h3\u003e\n\u003cp\u003eAntiplatelet regimen options were as follows: a) no antiplatelet medication within first 24-hour; b) overnight infusion of iv tirofiban which then followed by oral DAPT; c)1mg iv tirofiban followed by oral administration of clopidogrel\u0026thinsp;+\u0026thinsp;ASA or ticagrelor\u0026thinsp;+\u0026thinsp;ASA immediately after the procedure.\u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was symptomatic intracranial hemorrhage. Secondary outcomes included any intracranial hemorrhage, reperfusion success (TICI), 24-hour NIHSS, 90-day modified Rankin Scale (mRS), and follow-up extracranial ICA patency.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS version 27. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median (min\u0026ndash;max) and compared using appropriate parametric or non-parametric tests. Categorical variables were compared using chi-square or Fisher\u0026rsquo;s exact tests. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eA total of 268 consecutive patients with acute ischemic stroke due to tandem lesions were included (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The mean age was 66.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4 years (median 66; range 44\u0026ndash;93), and 190 patients (70.9%) were male. Vascular risk factors included hypertension in 76.9%, diabetes mellitus in 34.0%, hyperlipidemia in 79.9%, and coronary artery disease in 29.5%. Atrial fibrillation was present in 12.3% of patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline clinical and imaging characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePTA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCoronary stent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-expanding stent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline NIHSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline ASPECTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCore volume (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.9\u0026thinsp;\u0026plusmn;\u0026thinsp;50.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.0\u0026thinsp;\u0026plusmn;\u0026thinsp;51.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.6\u0026thinsp;\u0026plusmn;\u0026thinsp;51.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperlipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.490\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eContinuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD and compared using one-way ANOVA. Categorical variables are presented as percentages and compared using χ\u0026sup2; test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding extracranial treatment strategy, 63 patients (23.5%) underwent percutaneous transluminal angioplasty (PTA), 56 patients (20.9%) received balloon-expandable stents as bridging therapy, and 149 patients (55.6%) were treated with self-expanding carotid stents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Clinical and Imaging Characteristics\u003c/h2\u003e \u003cp\u003eAt admission, the median NIHSS score was 14 (IQR 0\u0026ndash;25), and the median ASPECTS was 7 (IQR 1\u0026ndash;10). Imaging characteristics are given in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Baseline perfusion imaging was available in 66.4% of patients. The median ischemic core volume (ADC\u0026thinsp;\u0026lt;\u0026thinsp;620 \u0026micro;m\u0026sup2;/s) was 21 mL, with a median mismatch ratio of 3. Intracranial occlusions most frequently involved the M1 segment (52.2%), followed by the ICA terminus (25.0%) and M2 segment (20.5%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProcedural and early imaging characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePTA (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBalloon-expandable stent (n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-expanding stent (n\u0026thinsp;=\u0026thinsp;149)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline NIHSS, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (11\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (15\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (8\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline ASPECTS, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (6\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (7\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial occlusion M1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33/62 (53.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26/56 (46.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79/150 (52.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial occlusion ICA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/62 (29.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19/56 (33.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31/150 (20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial occlusion M2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/62 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9/56 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37/150 (24.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst-pass reperfusion (TICI \u0026ge;2B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44/62 (71.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46/56 (82.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131/150 (87.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal reperfusion (TICI \u0026ge;2B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56/62 (90.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54/56 (96.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150/150 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24-hour NIHSS, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (4\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (4\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (2\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24-hour ASPECTS, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (6\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eValues are presented as n/N (%) for categorical variables and as median (IQR) for continuous variables. Between-group comparisons were performed using χ\u0026sup2; test for categorical variables and Kruskal\u0026ndash;Wallis test for continuous variables.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInitial imaging modality did not differ significantly among treatment groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, baseline stroke severity differed significantly across groups. Patients treated with coronary stents had higher baseline NIHSS scores compared with those treated with self-expanding stents (p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eBaseline ASPECTS also differed significantly among groups (p\u0026thinsp;=\u0026thinsp;0.001), with lower ASPECTS values observed in the coronary stent group compared with both PTA and self-expanding stent groups (both p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThe proportion of patients undergoing baseline perfusion-weighted imaging did not differ significantly between groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, ischemic core volume differed significantly (p\u0026thinsp;=\u0026thinsp;0.001), with larger core volumes observed in the coronary stent group compared with the self-expanding stent group. Mismatch ratio also differed among groups (p\u0026thinsp;=\u0026thinsp;0.040), with higher mismatch ratios in the self-expanding stent group compared with the coronary stent group (p\u0026thinsp;=\u0026thinsp;0.024).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMedical Treatment and Endovascular Therapy\u003c/h2\u003e \u003cp\u003eIntravenous thrombolysis was administered in 24 patients (9.0%). Median time from symptom onset to hospital arrival was 248 minutes, door-to-puncture time was 42 minutes, and puncture-to-recanalization time was 41 minutes.\u003c/p\u003e \u003cp\u003eFirst-pass reperfusion differed significantly among extracranial treatment strategies (p\u0026thinsp;=\u0026thinsp;0.033). Final successful recanalization (TICI\u0026thinsp;\u0026ge;\u0026thinsp;2b) was achieved in 96% of patients overall. Complete reperfusion (TICI 3) was achieved in 46.3% of patients and differed significantly among groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with lower rates observed in the PTA group compared with stent-treated patients.\u003c/p\u003e \u003cp\u003eA multivariable logistic regression analysis was performed to identify independent predictors of favorable functional outcome (mRS 0\u0026ndash;2) and intracranial hemorrhage (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). No independent predictors of symptomatic intracranial hemorrhage were identified. After adjustment for age, baseline NIHSS, ASPECTS, final TICI grade, and extracranial treatment strategy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), independent predictors of favorable outcome included younger age (OR 0.95, 95% CI 0.92\u0026ndash;0.98, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), lower baseline NIHSS (OR 0.91, 95% CI 0.86\u0026ndash;0.97, p\u0026thinsp;=\u0026thinsp;0.002), higher ASPECTS (OR 1.35, 95% CI 1.13\u0026ndash;1.61, p\u0026thinsp;=\u0026thinsp;0.001), and achievement of complete reperfusion (TICI 3) (OR 1.93, 95% CI 1.08\u0026ndash;3.46, p\u0026thinsp;=\u0026thinsp;0.026). Extracranial treatment strategy was not independently associated with favorable functional outcome or intracranial hemorrhage.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eEarly (first 24-hour) antithrombotic treatment according to extracranial strategy\u003c/b\u003e Early treatment type (among treated patients)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePTA (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBalloon-expandable (n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-expanding (n\u0026thinsp;=\u0026thinsp;149)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo antiplatelet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (67.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (71.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny antiplatelet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (32.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e142 (95.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePTA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBalloon-expandable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-expanding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGP IIb/IIIa (Aggrastat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75 (53.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClopidogrel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (17.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA\u0026thinsp;+\u0026thinsp;Clopidogrel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27 (18.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTicagrelor\u0026thinsp;+\u0026thinsp;ASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eValues are presented as n (%). Comparisons were performed using χ\u0026sup2; tests.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePeriprocedural and Early Antiplatelet Therapy\u003c/h2\u003e \u003cp\u003eAntiplatelet therapy within the first 24 hours was administered in 67.4% of patients (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Early antiplatelet use differed significantly between treatment strategies (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients treated with self-expanding stents were more likely to receive early antiplatelet therapy (95.3%) compared with PTA (32.8%) and coronary stent (28.6%) groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHemorrhagic outcomes according to extracranial treatment strategy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePTA (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBalloon-expandable (n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-expanding (n\u0026thinsp;=\u0026thinsp;149)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30/61 (49.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32/56 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59/149 (39.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esICH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7/61 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7/56 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13/149 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.674\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12/61 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11/56 (19.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30/149 (20.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.995\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8/61 (13.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10/56 (17.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8/149 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePH1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2/61 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/56 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8/149 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePH2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4/61 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3/56 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8/149 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSAH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7/61 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6/56 (10.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10/149 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.443\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eValues are presented as n/N (%). Comparisons performed using χ\u0026sup2; test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong patients receiving early therapy, glycoprotein IIb/IIIa inhibitors (primarily tirofiban) were the most frequently used agents, particularly in the self-expanding stent group (53.6%). Dual-antiplatelet therapy was more commonly prescribed at discharge following stent implantation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSafety Outcomes\u003c/h2\u003e \u003cp\u003eAny intracranial hemorrhage (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) occurred in 121 patients (45.1%), while symptomatic intracranial hemorrhage (sICH) occurred in 27 patients (10.1%). Rates of any hemorrhage and sICH did not differ significantly between extracranial treatment strategies (p\u0026thinsp;=\u0026thinsp;0.071 and p\u0026thinsp;=\u0026thinsp;0.598, respectively).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFunctional and imaging outcomes according to extracranial strategy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePTA (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBalloon-expandable (n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-expanding (n\u0026thinsp;=\u0026thinsp;149)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFavorable outcome (mRS 0\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30/62 (48.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33/56 (58.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e106/150 (70.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality (mRS 6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17/62 (27.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8/56 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23/150 (15.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRe-occlusion on follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6/62 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10/56 (17.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16/150 (10.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eValues are presented as n/N (%). Comparisons performed using χ\u0026sup2; test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHemorrhage subtype analysis revealed a significant difference in HT2 rates (p\u0026thinsp;=\u0026thinsp;0.018), with higher HT2 frequency in the coronary stent group compared with the self-expanding stent group. No significant differences were observed for SAH, HT1, PH1, or PH2 across groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFunctional and Imaging Outcomes\u003c/h2\u003e \u003cp\u003eAt 90 days (Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e), favorable functional outcome (mRS 0\u0026ndash;2) was achieved in 169 patients (63.1%). Functional outcomes differed significantly according to extracranial treatment strategy (p\u0026thinsp;=\u0026thinsp;0.004), with the highest rate of favorable outcome observed in the self-expanding stent group (71.1%), compared with the PTA (47.6%) and coronary stent (58.9%) groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable logistic regression for favorable outcome (mRS 0\u0026ndash;2)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI low\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI high\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTA vs Self-expanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.581\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalloon-expandable vs Self-expanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.777\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.949\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.923\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline NIHSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.914\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline ASPECTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.607\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal TICI 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFollow-up imaging demonstrated persistent or recurrent occlusion in 11.2% of patients, with no significant difference among treatment strategies (p\u0026thinsp;=\u0026thinsp;0.250).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this real-world cohort of patients with tandem occlusions undergoing thrombectomy, extracranial management strategy was not associated with differences in symptomatic intracranial hemorrhage despite substantial variability in early antiplatelet therapy. These findings suggest that hemorrhagic risk in tandem occlusion management is multifactorial and not determined by device selection alone. Management of tandem occlusions nevertheless remains challenging because these patients were largely excluded from the pivotal thrombectomy trials, leaving the optimal treatment of the extracranial lesion unresolved \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. Achieving carotid patency while minimizing hemorrhagic transformation creates a therapeutic dilemma, particularly in patients with large infarct cores or low ASPECTS, in whom reperfusion injury and early antithrombotic exposure may increase bleeding risk \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e. Among various strategies for management of tandem occlusions \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/sup\u003e, balloon-expandable stents used as a bridging strategy with delayed or less intensive antiplatelet therapy have been proposed as a potential solution, with early single-center data suggesting reduced rates of symptomatic intracranial hemorrhage \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe compared three acute extracranial management strategies—percutaneous transluminal angioplasty, balloon-mounted coronary stenting, and self-expanding carotid stenting—with a primary focus on hemorrhagic complications and clinical outcomes. Despite substantial differences in baseline infarct burden and early antiplatelet therapy across treatment groups, symptomatic intracranial hemorrhage did not differ among strategies (p = 0.598). Similarly, no statistically significant differences were observed in overall hemorrhage (p = 0.071), hemorrhagic transformation (p = 0.377), PH1 (p = 0.651), or PH2 (p = 0.813). These findings suggest that extracranial device selection alone may not be a major determinant of hemorrhagic complications in tandem occlusion management.\u003c/p\u003e \u003cp\u003eThe bridging strategy was developed on the premise that a short balloon-expandable coronary stent with relatively low metal load may provide focal plaque stabilization and maintain carotid patency while allowing avoidance or delay of early antiplatelet therapy during the hyperacute phase. Although early report suggested a potential safety advantage with this strategy \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e, we did not observe a reduction in symptomatic intracranial hemorrhage or other major hemorrhagic endpoints compared with angioplasty or conventional self-expanding carotid stenting. In our cohort, baseline NIHSS (p = 0.001), ASPECTS (p = 0.001), and infarct core volume (p = 0.001) differed significantly among treatment groups, with a less favorable ischemic profile in the coronary stent group. Despite this imbalance, symptomatic hemorrhage rates were not increased. Although HT2 was more frequent in the coronary stent group (p = 0.018), this radiological difference did not translate into higher symptomatic hemorrhage or worse functional outcomes.\u003c/p\u003e \u003cp\u003eAnother important observation is that early antithrombotic strategies differed significantly among treatment groups (p = 0.001), yet this variability was not associated with higher rates of symptomatic intracranial hemorrhage (p = 0.598). Early re-occlusion rates on follow-up imaging were also similar across strategies (p = 0.250). These findings are consistent with pooled registry analyses such as the TITAN collaboration, which likewise did not demonstrate a clear association between early antiplatelet therapy during endovascular treatment and long-term favorable outcomes in tandem occlusions \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e. Together, these data suggest that early antiplatelet intensity alone may not be the primary determinant of clinically meaningful hemorrhagic complications in this setting.\u003c/p\u003e \u003cp\u003eIn unadjusted analyses, self-expanding carotid stenting was associated with higher rates of favorable functional outcome (mRS 0–2, p = 0.004), accompanied by differences in procedural and early post-procedural parameters, including final reperfusion grades (TICI, p = 0.001), 24-hour ASPECTS (p = 0.001), and 24-hour NIHSS (p = 0.001). However, after multivariable adjustment, favorable outcome was independently determined by age, baseline neurological deficit, infarct burden, and successful reperfusion, while extracranial treatment strategy—including direct comparison between self-expanding and balloon-expandable stents—was not independently associated. These findings suggest that observed functional differences across treatment strategies likely reflect baseline case selection and reperfusion success rather than intrinsic device-related effects.\u003c/p\u003e \u003cp\u003eEvidence guiding extracranial management in tandem occlusions remains limited and is largely derived from retrospective analyses and registry data. Large pooled studies, including the TITAN\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e and ETIS collaborations\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/sup\u003e, have reported heterogeneous results regarding the impact of periprocedural antiplatelet therapy and extracranial stenting strategies on clinical outcomes and safety. In this context, our findings suggest that device selection alone should not be assumed to confer a hemorrhagic or functional advantage. Instead, treatment decisions should be individualized based on infarct burden, procedural considerations, and the anticipated need for durable carotid reconstruction.\u003c/p\u003e \u003cp\u003eAlthough our findings did not demonstrate a reduction in symptomatic intracranial hemorrhage with balloon-expandable bridging therapy, this does not preclude its potential value in selected clinical scenarios. In practice, situations such as large infarct cores, low ASPECTS, recent intravenous thrombolysis, or perceived high hemorrhagic risk may reasonably lead operators to favor a strategy that allows delayed initiation of antiplatelet therapy. In such contexts, balloon-expandable stenting may serve as a targeted strategy rather than a default approach for all tandem occlusions.\u003c/p\u003e \u003cp\u003eTaken together, our findings suggest that extracranial device selection alone does not determine hemorrhagic risk or functional outcome in patients with tandem occlusions undergoing thrombectomy. Instead, outcomes appear to be primarily driven by baseline infarct burden, neurological severity, and successful reperfusion. While balloon-expandable stenting may represent a pragmatic option in selected patients in whom early antiplatelet therapy is undesirable, our data do not support routine use of this strategy solely for presumed hemorrhagic protection. Future prospective studies are needed to better define patient subgroups that may benefit from tailored extracranial management strategies.\u003c/p\u003e "},{"header":"Limitations","content":"\u003cp\u003eThis study has limitations inherent to its retrospective single-center design, and treatment allocation was based on operator judgment rather than randomization. As a result, baseline clinical and imaging characteristics differed among groups, reflecting real-world practice. Antiplatelet strategies were not protocolized and varied according to clinical context. Although multivariable analysis was performed to account for major prognostic factors, unmeasured influences related to treatment selection cannot be entirely excluded. In addition, follow-up assessment of carotid patency was based on available imaging rather than a standardized surveillance schedule. Nevertheless, the consecutive cohort, detailed imaging characterization, and comparative evaluation of three commonly used extracranial strategies provide relevant insights into contemporary management of tandem occlusions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this large real-world cohort of patients with tandem occlusions, extracranial management strategy was not associated with differences in symptomatic intracranial hemorrhage despite substantial variability in early antiplatelet therapy. Although unadjusted analyses suggested differences in functional outcomes across treatment strategies, these associations were no longer significant after multivariable adjustment, with recovery primarily determined by baseline neurological status, infarct burden, and successful reperfusion. These findings indicate that hemorrhagic and functional outcomes in tandem occlusions are multifactorial and not determined by device selection alone. Accordingly, extracranial reconstruction should be individualized, integrating patient characteristics, procedural considerations, and long-term vascular objectives.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eEthics approval\u003c/h2\u003e\n\u003cp\u003eStudy was conducted according to Declaration of Helsinki. This study was approved by the Institutional Review Board of Istanbul Aydin University with document number of 2023/140.The requirement for informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\n\u003ch2\u003ePatient consent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eData availability statement\u003c/h2\u003e\n\u003cp\u003eData are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003eAuthor contributions\u003c/h2\u003e\n\u003cp\u003eSG and AB conceived the study and supervised the project. [SS and AB] collected the data. [SA] performed statistical analysis. SG and [AB] drafted the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThe authors thank the stroke and neurointerventional teams involved in patient care and data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMalhotra K, Goyal N, Tsivgoulis G, et al. Endovascular treatment of tandem occlusions in acute ischemic stroke. Stroke. 2019;50:3487\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson MP, Murad MH, Krings T, et al. Management of tandem occlusions in acute ischemic stroke. Stroke. 2018;49:211\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePapanagiotou P, Haussen DC, Turjman F, et al. Carotid stenting and mechanical thrombectomy in tandem occlusions. Stroke. 2018;49:2380\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA versus t-PA alone in stroke. N Engl J Med. 2015;372:2285\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296\u0026ndash;306.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun CHJ, Connelly K, Nogueira RG, et al. ASPECTS decay during inter-facility transfer predicts patient outcomes in endovascular reperfusion for ischemic stroke: a unique assessment of dynamic physiologic change over time. J NeuroInterventional Surg. 2015;7(1):22\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeh-Gonik U, Tau N, Friehmann T, et al. Thrombectomy outcomes for acute stroke patients with anterior circulation tandem lesions: a clinical registry and an update of a systematic review with meta-analysis. Eur J Neurol. 2018;25:693\u0026ndash;700.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnadani M, Marnat G, Consoli A, et al. Endovascular therapy of anterior circulation tandem occlusions: pooled analysis from the TITAN and ETIS registries. Stroke. 2021;52:3097\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLockau H, Liebig T, Henning T, et al. Mechanical thrombectomy in tandem occlusions. Stroke. 2015;46:353\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMpotsaris A, Bussmeyer M, Buchner H, et al. Clinical outcome of mechanical thrombectomy in tandem occlusions. Neuroradiology. 2018;60:1067\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen JE, Gomori JM, Leker RR. Emergent stenting of extracranial carotid artery lesions during thrombectomy. J Neurointerv Surg. 2017;9:741\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodriguez-Villatoro N, Rodriguez-Luna D, Muchada M, et al. Balloon-expandable stenting as a bridging therapy in patients with acute stroke and tandem occlusions. Stroke Vasc Interv Neurol. 2023;3(5):e000825.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson JT, Hareendran A, Grant M, et al. Improving the assessment of outcomes in stroke: use of a structured interview to assign grades on the modified Rankin Scale. Stroke. 2002;33(9):2243\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrott T, Adams HP Jr, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20(7):864\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet. 2000;355(9216):1670\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Kummer R, Broderick JP, Campbell BCV, et al. The Heidelberg Bleeding Classification: Classification of Bleeding Events After Ischemic Stroke and Reperfusion Therapy. Stroke. 2015;46(10):2981\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStampfl S, Ringleb PA, M\u0026ouml;hlenbruch MA, et al. Emergency cervical carotid artery stenting in combination with thrombectomy. AJNR Am J Neuroradiol. 2014;35:741\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBehme D, Mpotsaris A, Zeyen P, et al. Emergency stenting of the extracranial carotid artery during thrombectomy. AJNR Am J Neuroradiol. 2015;36:2130\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGory B, Haussen DC, Piotin M, et al. Impact of extracranial carotid lesion treatment on outcome in tandem occlusion stroke. Stroke. 2018;49:2384\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiebeskind DS, Flint AC, Budzik RF, et al. Carotid revascularization strategies in tandem occlusion stroke. Stroke. 2020;51:2277\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnadani M, Spiotta AM, Alawieh A, et al. Emergent Carotid Stenting Plus Thrombectomy After Thrombolysis in Tandem Stroke: Analysis of the TITAN Registry. Stroke. 2019;50(8):2250\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnadani M, Alawieh A, Jabbour P, et al. Impact of Cervical Carotid Stenting in Tandem Occlusion Strokes Treated with Thrombectomy: Insights from the TITAN Collaboration. Stroke. 2021;52(1):e5\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeh-Gonik U, Gory B, Consoli A, et al. Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Stroke Treated with Thrombectomy: Results from the ETIS Registry. Eur J Neurol. 2018;25(4):610\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9354360/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9354360/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u003c/p\u003e\n\u003cp\u003eOptimal extracranial management in acute ischemic stroke due to tandem occlusions remains controversial. Balloon-expandable stents used as a bridging strategy with reduced early antiplatelet therapy have been proposed to decrease hemorrhagic risk, but comparative real-world data are limited.\u003c/p\u003e\n\u003cp\u003eMethods:\u003c/p\u003e\n\u003cp\u003eWe retrospectively analyzed 268 consecutive patients with tandem lesions treated with mechanical thrombectomy and one of three extracranial strategies: percutaneous transluminal angioplasty (PTA, n = 63), balloon-mounted coronary stenting (n = 56), or self-expanding carotid stenting (n = 149). The primary endpoint was symptomatic intracranial hemorrhage (sICH). Secondary endpoints included hemorrhagic subtypes, reperfusion metrics, re-occlusion, and 90-day functional outcome (mRS).\u003c/p\u003e\n\u003cp\u003eResults:\u003c/p\u003e\n\u003cp\u003eBaseline stroke severity differed among groups, with higher NIHSS scores and larger core volumes in the coronary stent group (p = 0.001). Early antiplatelet therapy within 24 hours also differed significantly (p \u0026lt; 0.001). sICH occurred in 10.1% and did not differ among groups (p = 0.598). Rates of any hemorrhage (p = 0.071), hemorrhagic transformation (p = 0.377), PH1 (p = 0.651), and PH2 (p = 0.813) were comparable, although HT2 was more frequent in the coronary group (p = 0.018). Final TICI grades differed significantly (p \u0026lt; 0.001). Favorable functional outcome (mRS 0–2) at 90 days was highest in the self-expanding stent group (71.1%) compared with PTA (47.6%) and coronary stenting (58.9%) (p = 0.004). However, in multivariable analysis, favorable outcome was independently associated with younger age, lower NIHSS, higher ASPECTS, and complete reperfusion, while extracranial strategy was not independently associated. Re-occlusion rates did not differ (p = 0.250).\u003c/p\u003e\n\u003cp\u003eConclusions:\u003c/p\u003e\n\u003cp\u003eExtracranial device selection was not associated with differences in symptomatic intracranial hemorrhage despite substantial variability in antiplatelet therapy. Self-expanding stenting was associated with superior functional outcome without increased bleeding risk, supporting individualized management strategies.\u003c/p\u003e","manuscriptTitle":"Extracranial Reconstruction Strategies for Management of Acute Tandem Occlusion Strokes: Hemorrhage risks and functional outcome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-21 15:00:06","doi":"10.21203/rs.3.rs-9354360/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"186588858019997481101644324022317232967","date":"2026-05-10T11:12:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T13:31:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29582924062308293346626214961204622604","date":"2026-04-15T23:39:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3453966302567984478216572547987425306","date":"2026-04-14T04:58:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151507635725545360963862112982876393024","date":"2026-04-14T03:24:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-13T20:26:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T20:20:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-13T17:10:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-13T16:27:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2026-04-13T13:12:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4f2753eb-f7b6-4f61-9112-b39a273460d9","owner":[],"postedDate":"April 21st, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"186588858019997481101644324022317232967","date":"2026-05-10T11:12:46+00:00","index":28,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T13:31:06+00:00","index":25,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T15:00:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-21 15:00:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9354360","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9354360","identity":"rs-9354360","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}