Technical Effectiveness and Safety of Emergent Stenting in Patients With Acute Ischemic Stroke and Carotid Near-Occlusion

Technical Effectiveness and Safety of Emergent Stenting in Patients With Acute Ischemic Stroke and Carotid Near-Occlusion | 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 Technical Effectiveness and Safety of Emergent Stenting in Patients With Acute Ischemic Stroke and Carotid Near-Occlusion Andrés García Pastor, Isabel Lera Ramírez, Alejandro Bonilla Tena, and 21 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7225884/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Sep, 2025 Read the published version in Neuroradiology → Version 1 posted You are reading this latest preprint version Abstract BACKGROUND: The increased very early risk (within the first 2 days after presenting event) of recurrent stroke among patients with symptomatic carotid near-occlusion (SCNO) and full collapse (FC) might justify ultra-early carotid revascularization of these patients. However, we lack data about technical effectiveness and safety of this approach in SCNO. This study aims to assess the feasibility and safety of emergent carotid stenting (eCAS) in patients with SCNO. METHODS: multicenter study including patients with acute stroke and extracranial carotid stenosis or occlusion undergoing mechanical thrombectomy and eCAS. The main outcomes were revascularization failure (incomplete carotid revascularization/occlusion at 48h), intracerebral hemorrhage (ICH) and symptomatic ICH (sICH). Patients with SCNO with and without FC were compared with the remaining patients. RESULTS: 309 patients were included, 215 (69.6%) males, mean age (SD) 67.2 (12.8). 52 patients had SCNO and 18 SCNO+FC. Revascularization failure occurred in 16% of SCNO and in 15.2% of the remaining patients (p=0.884), with no differences between SCNO with or without FC. ICH was more common in patients with SCNO (37% for all SCNO, 41% for SCNO+FC, and 23% for the remaining patients; p=0.033). This increased risk of ICH associated with SCNO persisted in the multivariate analysis (OR 2.84 [95%CI 1.41 – 5.71], p=0.003). The rate of sICH was identical (6%) for SCNO and the rest of patients. CONCLUSIONS: The use of eCAS in acute SCNO seems to be feasible. However, the safety of the procedure is uncertain, as it could be associated with an increased risk of ICH. Figures Figure 1 INTRODUCTION Carotid near-occlusion (CNO) is defined as a severe stenosis of the extracranial internal carotid artery (ICA) that causes a reduction of the caliber of the artery beyond the stenosis. CNO can be classified as with or without full collapse (FC), which is defined as a thread-like lumen distal to the stenosis ( 1 ). Although the risk of ipsilateral stroke in patients with CNO remains a controversial issue, an increased very early risk of recurrent stroke (within the first 2 days after presenting event) has recently been described among patients with symptomatic CNO and FC ( 2 ). These findings would justify emergent revascularization in these patients with the aim of avoiding early recurrences. Recent studies suggest that the use of emerging carotid stenting (eCAS) in patients with acute ischemic stroke caused by a tandem occlusion (occlusion or severe stenosis of the extracranial ICA + occlusion of an ipsilateral intracranial artery) is correlated with a higher rate of recanalization and improved 90-day functional outcome compared to non-stenting approaches ( 3 ). Effectiveness and safety of eCAS in patients with symptomatic CNO is unknown. The objective of this study is to assess the technical effectiveness and safety of e-CAS in patients with CNO and an ipsilateral acute ischemic stroke. METHODS Study design & patient selection We conducted a retrospective analysis of prospectively collected data from a thrombectomy registry from January 2019 to December 2023 in eight comprehensive acute stroke centers in the Madrid Area. Patients with an acute ischemic stroke caused by a tandem occlusion (defined as the combination of an occlusion of an intracranial artery and the occlusion, near-occlusion or severe stenosis [> 50%] of the ipsilateral extracranial ICA) or by an isolated occlusion, near-occlusion or severe stenosis of an extracranial ICA were included. All patients underwent an eCAS +/- mechanical thrombectomy. The study was supported by the Madrid Stroke Network and was approved by the ethics committees of Gregorio Marañón University Hospital (record #06/2024) and the other participating institutions, in accordance with the basic ethical principles and standards established in the Declaration of Helsinki (revised version of Fortaleza, 2013). This study also complies with the Oviedo Convention and the regulatory requirements in force in Spanish legislation (basic regulations: Law 29/2006, of July 26, on guarantees and rational use of medicines and health products, and Law 14/2007, of July 3, on biomedical research; and specific regulations: Order SAS 3470/2009). Due to the retrospective nature of the study, informed consent was waived. The diagnosis of ICA occlusion, near-occlusion or stenosis was performed by each participating canter, based on the computed tomography-angiography (CTA) findings and was subsequently confirmed by the initial diagnostic angiographic series of the endovascular procedure. For CNO diagnosis, patients had to meet at least two of the four CTA criteria by Bartlett et al.: 1) narrowest diameter of the ICA bulb stenosis ≤ 1.3 mm. 2) diameter of the distal ICA ≤ 3.5 mm, 3) Ipsilateral distal ICA/ contralateral distal ICA ratio ≤ 0.87 and 4) ipsilateral distal ICA/ ipsilateral distal ECA ratio ≤ 1.27 ( 4 ).. FC was identified using the CTA criteria by Johansson et al.: distal ICA diameter ≤ 2.0 mm and/or ICA ratio ≤ 0.42 ( 5 ). Patient data and outcome measures Data were collected by each centre in a local registry that was subsequently merged in a joint database. The following variables were recorded: baseline demographics, vascular risk factors, medical history, clinical and radiologic features of stroke, intravenous thrombolysis prior to MT and eCAS, data of the revascularization procedures, intracerebral hemorrhage (asymptomatic and symptomatic), stent patency within 48 hours after the procedure, and functional outcome at 3 months using the modified Rankin scale (mRS). Stent patency was evaluated with ultrasounds within 24–48 hours after the procedure. The 3-month mRS score was assessed either at the outpatient stroke clinic or by telephone interview. Good functional outcome was defined as a mRS score 0–2. The main outcome measures were: 1) revascularization failure, defined as an occlusion or incomplete revascularization (persisting stenosis > 50%) of the ICA within the first 48 hours after the procedure, and 2) intracerebral hemorrhage (ICH) and symptomatic ICH (sICH) according to the European Cooperative Acute Stroke Study (ECASS) group classification ( 6 ). Patients with CNO were compared with the rest of patients (with an extracranial ICA occlusion or severe stenosis). In addition, patients with and without FC were compared with each other and with the remaining patients, and patients with CNO and tandem occlusion were compared with patients with CNO and isolated extracranial ICA involvement. Statistical analysis Statistical analyses were performed using IBM SPSS Statistics 24.0 software. The results were expressed as proportions for categorical variables and as means and the standard deviation (SD) or medians and the interquartile range (IQR) for continuous variables. Categorical variables were compared using the χ² test or two-tailed Fisher’s exact test. Means were compared using a 2-sample t test or ANOVA, for median comparison U Mann-Whitney or Kruskal-Wallis tests were used. CNO, FC and factors showing a significant association (p < 0.05) in the univariate analyses were included in a multivariate logistic regression analysis. P values ≤ 0.05 were considered statistically significant. RESULTS A total of 309 patients were included in the study. Differentiation of extracranial ICA involvement into occlusion, near-occlusion or stenosis could be obtained in 292 patients (94.5%). 202 (69.2%) were male, the mean age was 67.1 years (SD 12.9). CNO was identified in 52 patients (17.8%), 18 of whom were CNO with FC. Patients with CNO without FC presented more frequently with ACA or distal MCA occlusion, or isolated extracranial ICA involvement. No other differences were observed in the baseline characteristics, or other clinical or radiological aspects of the stroke (see table 1). CNO patients with isolated involvement of extracranial ICA had more frequently a history of stroke or ischemic heart disease and were more often on antithrombotic treatment (suppl. Table 2). Revascularization failure occurred in 42 patients (15.3%), 8 (16%) in the CNO group and 34 (15.2%) in the rest of patients (p=0.884). Revascularization failure was observed in 4 of 18 patients with CNO and FC (22%) and in 4 CNO patients without FC (12.5%), p=0.368 (see figure 1A). Age, terminal ICA (TICA) occlusion and reduced stent diameter were associated with an increased risk of revascularization failure in the bivariate analysis, however the effect disappeared after the multivariate adjustment, see table 2. Revascularization failed in 8 patients (20.5%) with CNO + tandem occlusion and in none with isolated involvement, p=0.101 (suppl table 3). Seventy-four patients (25.4%) suffered ICH, and this was more frequent in patients with CNO (37% for all the CNO cohort, 41% for CNO+FC compared with 23% for rest of patients; p=0.033). However, the rate of sICH was identical (6%) for CNO, FC subgroups and the rest of patients (see figure 1B and C). Each one-point increase in ASPECTS score and achievement of mTICI 2c/3 protected against ICH, while CNO was associated with an increased risk of ICH in the multivariate analysis. Intravenous thrombolysis (IVT) was the only factor associated with sICH in the multivariate analysis (table 3). ICH was more frequent in CNO with intracranial occlusion (44% compared to 10% in CNO without intracranial involvement, p=0.047), see suppl. Table 3. Good functional outcome (mRS 0 – 2) at 3 months was achieved by 143 patients (55%), 65% of patients with CNO reached the outcome while 53% of the rest of patients did, p=0.132 (see figure 1D). Age, stroke severity, IVT, obtaining mTICI 2c/3, the use of clopidogrel during the procedure and suffering sICH after the procedure were related with functional outcome, while CNO or CNO+FC did not affect the outcome of our patients (see supplemental table 1). DISCUSSION The main findings of this study were that, compared with other types of ICA stenosis or occlusion, eCAS in patients with CNO is technically feasible and effective, although associated with a higher rate of intracerebral hemorrhage. It has recently been observed that the risk of recurrent stroke in patients with symptomatic CNO is particularly high during the first two days after the event, and especially in patients with full collapse ( 2 ). This fact would justify ultra-early revascularization to avoid these early recurrences. In this sense, emergent carotid artery stenting (eCAS), which is increasingly being used in patients with stroke due to tandem occlusion ( 3 ), could be considered a good strategy for these patients. However, it is important to note that stent placement in CNO is a technically challenging procedure (especially in cases with full collapse) as it involves crossing a very severe stenosis and expanding the stent in a very narrow artery ( 7 , 8 ). Moreover, in the context of acute stroke the technical difficulty may be even greater and the risk-benefit margin narrower. In this study, revascularization failure rates were similar for CNO and for patients with ICA occlusion or "conventional" stenosis (16% and 15%, respectively), and no significant differences were observed between patients with and without full collapse (22% and 12.5% ​​respectively, p = 0.368). This result contrasts with previous data in which a higher incidence of revascularization failure was observed in patients with CNO and full collapse (33% compared with 6% in patients without full collapse) ( 7 ). The safety of carotid revascularization in CNO, and especially in CNO with full collapse, remains a matter of debate. A higher incidence of cerebral hyperperfusion syndrome has been reported in patients with CNO undergoing CAS, reaching up to 30% of patients with CNO and full collapse ( 9 ). A higher rate of perioperative events and post-procedural stroke or death has also been observed in patients with CNO and full collapse ( 10 , 11 ). In our cohort, patients with CNO undergoing eCAS had a higher rate of ICH (37%, 41% in the subgroup of CNO with full collapse versus 23% in all other patients). A previous report by Johansson et al. also observed a high rate of ICH (2 out of 10 cases, one of them fatal) after revascularization of CNO with full collapse patients ( 11 ). It has been proposed that flow reduction associated with full collapse and hyperperfusion after revascularization may be involved in the pathophysiology of this phenomenon. In our study, performing carotid revascularisation during the acute stage of stroke may also have increased the risk of hemorrhagic transformation. However, it is important to highlight that despite the observed higher rate of any ICH in CNO patients in our cohort, this did not translate into increased rates of symptomatic ICH or poorer 3-month functional outcomes compared to other groups. This suggests that many of these hemorrhagic events might be of minor clinical significance (e.g., petechial hemorrhages), a finding that could nuance the perception of the procedure's safety profile in this specific population, indicating that the increased ICH risk may not necessarily lead to worse clinical sequelae. In this study, we compared the effects of eCAS in patients with CNO and tandem occlusion versus patients with isolated ICA involvement (ie, CNO without intracranial occlusion). We made this distinction because we believe that these are two subgroups with significant differences in the mechanism involved in stroke (embolism in patients with tandem occlusion versus hypoperfusion in patients with isolated ICA involvement) and, therefore, there may be differences in treatment outcomes or complications. We detected no differences between the two groups in the rate of technical failure, nor in functional outcome at 3 months. However, the subgroup with tandem occlusion had a higher rate of ICH. This last finding could be paradoxical considering that post-revascularization hyperperfusion syndrome and higher risk of ICH would be more expected in the group with isolated extracranial ICA involvement. This observation is nevertheless limited by the small number of patients analyzed and should be confirmed in larger cohorts. This study has several limitations. First, the study only assessed the feasibility and safety of eCAS in patients with CNO and acute stroke, as part of the acute endovascular treatment of these patients. Since there was no control group, the effect of the procedure on recurrence prevention could not be analysed. Second, the analysed data came from a registry of mechanical thrombectomy in acute stroke, not specifically designed to evaluate the effect of eCAS in patients with CNO. Third, the small sample size could have affected the statistical power of the study, limiting the ability to analyse patient subgroups (CNO with FC, isolated extracranial ICA involvement, etc.) and to identify factors associated with the assessed outcomes. Finally, the diagnosis of CNO and FC was not centralized, and therefore diagnostic errors may have occurred, especially "false" FC images produced by intracranial occlusions rather than CNO. In conclusion, the use of emergent carotid stenting in patients with carotid near-occlusion appears to be feasible, both in patients with ipsilateral acute stroke due to tandem occlusion and those without intracranial occlusion. However, the safety of the procedure is uncertain, as it could be associated with an increased risk of intracerebral hemorrhage. Our results highlight the need for larger studies to establish the safety and usefulness of emergent revascularization therapy in patients with symptomatic carotid near-occlusion. Declarations Ethical approval The Ethics committees of Gregorio Marañón University Hospital approved this study (Record #06/2024) Informed consent informed consent was waived because of the retrospective nature of this study. Funding and/or Conflicts of interests/Competing interests The authors declare to have no conflict of interest. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution AGP contributed the conception and design of the study; AGP, ILR, ABT, DS, PC, FO, EdC-R, CGE, PS, AL-FL-J, DPG, RVL, CM, JCF-F, MTMM, JRE, AGT, INV, EEE, RTC, GMA, AMIM, MVM and AGN contributed to the acquisition and analysis of data and drafting the text. References Johansson E, Fox A (2016) Carotid Near-Occlusion: A Comprehensive Review, Part 1— Definition, Terminology, and Diagnosis. AJNR Am J Neuroradiol 37:2–10 Henze A, Fox AJ, Johansson E (2024) High risk of early recurrent stroke in patients with near-occlusion with full collapse of the internal carotid artery. Neuroradiology 66(3):349–352 Wei W, Zhang J, Xie S, Fan D, Chen Y, Zhong C et al (2024) Acute carotid stenting versus non-stenting treatment of acute ischemic stroke due to tandem lesions: a systematic review and meta-analysis. J Neurol 271:5713–5721 Bartlett ES, Walters TD, Symons PSFA (2006) Diagnosing Carotid Stenosis Near-Occlusion by Using CT Angiography. AJNR Am J Neuroradiol 27:632–637 Johansson E, Gu T, Fox AJ (2021) Defining carotid near occlusion with full collapse : a pooled analysis. Neuroradiology 64:59–67 Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D et al (2008) for the EInvestigators. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. N Engl J Med 359:1317–1329 Garcia-Pastor A, Gil-Núñez A, Ramirez-Moreno JM, González-Nafría N, Tejada J, Moniche F et al (2022) Endarterectomy, Stenting, or Medical Treatment for Symptomatic Carotid Near-Occlusion: Results from CAOS, a Multicenter Registry Study. Am J Neuroradiol 43(9):1304–1310 Neves CRB, Casella IB, da Silva ES, Puech-Leão P (2018) Medical Therapy for Asymptomatic Patients and Stent Placement for Symptomatic Patients Presenting with Carotid Artery Near-Occlusion with Full Collapse. J Vasc Interv Radiol 29(7):998–1005 Cay F, Cil BE, Balci S, Arsava EM, Topçuoǧlu MA, Arat A (2020) Relevance of distal arterial collapse in stenting of atherosclerotic near-occlusion of the carotid artery. Am J Neuroradiol 41(6):1054–1060 Pagliariccio G, Di Sario I, Capoccia L, D’Elia M, Bafile G, Leopardi M et al (2024) Carotid Near-Occlusion: Surgical or Conservative Management? Retrospective Multicenter Study. Annals of Vascular Surgery. Elsevier Inc., pp 133–139 Johansson E, Gu T, Castillo S, Brunström M, Holsti M, Wanhainen A (2022) Intracerebral Haemorrhage after Revascularisation of Carotid Near Occlusion with Full Collapse. European J Vasc Endovasc Surg [Internet]. ;63:523–4. Available from: https://doi.org/10.1016/j.ejvs.2021.10.057 Tables Table 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files SupplTables.docx Table13.docx Cite Share Download PDF Status: Published Journal Publication published 30 Sep, 2025 Read the published version in Neuroradiology → Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":231462,"visible":true,"origin":"","legend":"\u003cp\u003eMain outcome measures. Comparison between groups. \u0026nbsp;A) Revascularization failure. B) Intracerebral hemorrhage. C) symptomatic intracerebral hemorrhage. D) modified Rankin Scale score at 3 months.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCNO, carotid near-occlusion; FC, full collapse.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"figura1AD.png","url":"https://assets-eu.researchsquare.com/files/rs-7225884/v1/620a665520cd8a15509bba93.png"},{"id":92884430,"identity":"6fdf9da4-5dd5-4207-b982-55e2897207bc","added_by":"auto","created_at":"2025-10-06 16:12:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":786449,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7225884/v1/ebbfa39d-c21e-4993-b417-9f8d50711681.pdf"},{"id":88645367,"identity":"ab8e6349-f722-410a-aadc-b010b6ce653e","added_by":"auto","created_at":"2025-08-08 16:24:14","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26393,"visible":true,"origin":"","legend":"","description":"","filename":"SupplTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7225884/v1/134ac48458c5503154733779.docx"},{"id":88643522,"identity":"46e33f5f-0037-44f0-8f1c-d863198c09c2","added_by":"auto","created_at":"2025-08-08 16:16:14","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":32899,"visible":true,"origin":"","legend":"","description":"","filename":"Table13.docx","url":"https://assets-eu.researchsquare.com/files/rs-7225884/v1/a705e79af6a4920fe4a9ae0b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTechnical Effectiveness and Safety of Emergent Stenting in Patients With Acute Ischemic Stroke and Carotid Near-Occlusion\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCarotid near-occlusion (CNO) is defined as a severe stenosis of the extracranial internal carotid artery (ICA) that causes a reduction of the caliber of the artery beyond the stenosis. CNO can be classified as with or without full collapse (FC), which is defined as a thread-like lumen distal to the stenosis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although the risk of ipsilateral stroke in patients with CNO remains a controversial issue, an increased very early risk of recurrent stroke (within the first 2 days after presenting event) has recently been described among patients with symptomatic CNO and FC (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese findings would justify emergent revascularization in these patients with the aim of avoiding early recurrences.\u003c/p\u003e\u003cp\u003eRecent studies suggest that the use of emerging carotid stenting (eCAS) in patients with acute ischemic stroke caused by a tandem occlusion (occlusion or severe stenosis of the extracranial ICA + occlusion of an ipsilateral intracranial artery) is correlated with a higher rate of recanalization and improved 90-day functional outcome compared to non-stenting approaches (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEffectiveness and safety of eCAS in patients with symptomatic CNO is unknown. The objective of this study is to assess the technical effectiveness and safety of e-CAS in patients with CNO and an ipsilateral acute ischemic stroke.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cem\u003eStudy design \u0026amp; patient selection\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWe conducted a retrospective analysis of prospectively collected data from a thrombectomy registry from January 2019 to December 2023 in eight comprehensive acute stroke centers in the Madrid Area. Patients with an acute ischemic stroke caused by a tandem occlusion (defined as the combination of an occlusion of an intracranial artery and the occlusion, near-occlusion or severe stenosis [\u0026gt; 50%] of the ipsilateral extracranial ICA) or by an isolated occlusion, near-occlusion or severe stenosis of an extracranial ICA were included. All patients underwent an eCAS +/- mechanical thrombectomy. The study was supported by the Madrid Stroke Network and was approved by the ethics committees of Gregorio Marañón University Hospital (record #06/2024) and the other participating institutions, in accordance with the basic ethical principles and standards established in the Declaration of Helsinki (revised version of Fortaleza, 2013). This study also complies with the Oviedo Convention and the regulatory requirements in force in Spanish legislation (basic regulations: Law 29/2006, of July 26, on guarantees and rational use of medicines and health products, and Law 14/2007, of July 3, on biomedical research; and specific regulations: Order SAS 3470/2009). Due to the retrospective nature of the study, informed consent was waived.\u003c/p\u003e\u003cp\u003eThe diagnosis of ICA occlusion, near-occlusion or stenosis was performed by each participating canter, based on the computed tomography-angiography (CTA) findings and was subsequently confirmed by the initial diagnostic angiographic series of the endovascular procedure. For CNO diagnosis, patients had to meet at least two of the four CTA criteria by Bartlett et al.: 1) narrowest diameter of the ICA bulb stenosis ≤ 1.3 mm. 2) diameter of the distal ICA ≤ 3.5 mm, 3) Ipsilateral distal ICA/ contralateral distal ICA ratio ≤ 0.87 and 4) ipsilateral distal ICA/ ipsilateral distal ECA ratio ≤ 1.27 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).. FC was identified using the CTA criteria by Johansson et al.: distal ICA diameter ≤ 2.0 mm and/or ICA ratio ≤ 0.42 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient data and outcome measures\u003c/em\u003e\u003c/p\u003e\u003cp\u003eData were collected by each centre in a local registry that was subsequently merged in a joint database. The following variables were recorded: baseline demographics, vascular risk factors, medical history, clinical and radiologic features of stroke, intravenous thrombolysis prior to MT and eCAS, data of the revascularization procedures, intracerebral hemorrhage (asymptomatic and symptomatic), stent patency within 48 hours after the procedure, and functional outcome at 3 months using the modified Rankin scale (mRS).\u003c/p\u003e\u003cp\u003eStent patency was evaluated with ultrasounds within 24–48 hours after the procedure. The 3-month mRS score was assessed either at the outpatient stroke clinic or by telephone interview. Good functional outcome was defined as a mRS score 0–2.\u003c/p\u003e\u003cp\u003eThe main outcome measures were: 1) revascularization failure, defined as an occlusion or incomplete revascularization (persisting stenosis \u0026gt; 50%) of the ICA within the first 48 hours after the procedure, and 2) intracerebral hemorrhage (ICH) and symptomatic ICH (sICH) according to the European Cooperative Acute Stroke Study (ECASS) group classification (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Patients with CNO were compared with the rest of patients (with an extracranial ICA occlusion or severe stenosis). In addition, patients with and without FC were compared with each other and with the remaining patients, and patients with CNO and tandem occlusion were compared with patients with CNO and isolated extracranial ICA involvement.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics 24.0 software. The results were expressed as proportions for categorical variables and as means and the standard deviation (SD) or medians and the interquartile range (IQR) for continuous variables. Categorical variables were compared using the χ² test or two-tailed Fisher’s exact test. Means were compared using a 2-sample t test or ANOVA, for median comparison U Mann-Whitney or Kruskal-Wallis tests were used.\u003c/p\u003e\u003cp\u003eCNO, FC and factors showing a significant association (p \u0026lt; 0.05) in the univariate analyses were included in a multivariate logistic regression analysis. P values ≤ 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 309 patients were included in the study. Differentiation of extracranial ICA involvement into occlusion, near-occlusion or stenosis could be obtained in 292 patients (94.5%). 202 (69.2%) were male, the mean age was 67.1 years (SD 12.9). CNO was identified in 52 patients (17.8%), 18 of whom were CNO with FC. Patients with CNO without FC presented more frequently with ACA or distal MCA occlusion, or isolated extracranial ICA involvement. No other differences were observed in the baseline characteristics, or other clinical or radiological aspects of the stroke (see table 1). CNO patients with isolated involvement of extracranial ICA had more frequently a history of stroke or ischemic heart disease and were more often on antithrombotic treatment (suppl. Table 2).\u003c/p\u003e\n\u003cp\u003eRevascularization failure occurred in 42 patients (15.3%), 8 (16%) in the CNO group and 34 (15.2%) in the rest of patients (p=0.884). Revascularization failure was observed in 4 of 18 patients with CNO and FC (22%) and in 4 CNO patients without FC (12.5%), p=0.368 (see figure 1A). Age, terminal ICA (TICA) occlusion and reduced stent diameter were associated with an increased risk of revascularization failure in the bivariate analysis, however the effect disappeared after the multivariate adjustment, see table 2. Revascularization failed in 8 patients (20.5%) with CNO + tandem occlusion and in none with isolated involvement, p=0.101 (suppl table 3).\u003c/p\u003e\n\u003cp\u003eSeventy-four patients (25.4%) suffered ICH, and this was more frequent in patients with CNO (37% for all the CNO cohort, 41% for CNO+FC compared with 23% for rest of patients; p=0.033). However, the rate of sICH was identical (6%) for CNO, FC subgroups and the rest of patients (see figure 1B and C). Each one-point increase in ASPECTS score and achievement of mTICI 2c/3 protected against ICH, while CNO was associated with an increased risk of ICH in the multivariate analysis. Intravenous thrombolysis (IVT) was the only factor associated with sICH in the multivariate analysis (table 3). ICH was more frequent in CNO with intracranial occlusion (44% compared to 10% in CNO without intracranial involvement, p=0.047), see suppl. Table 3.\u003c/p\u003e\n\u003cp\u003eGood functional outcome (mRS 0 \u0026ndash; 2) at 3 months was achieved by 143 patients (55%), 65% of patients with CNO reached the outcome while 53% of the rest of patients did, p=0.132 (see figure 1D). Age, stroke severity, IVT, obtaining mTICI 2c/3, the use of clopidogrel during the procedure and suffering sICH after the procedure were related with functional outcome, while CNO or CNO+FC did not affect the outcome of our patients (see supplemental table 1).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe main findings of this study were that, compared with other types of ICA stenosis or occlusion, eCAS in patients with CNO is technically feasible and effective, although associated with a higher rate of intracerebral hemorrhage.\u003c/p\u003e\u003cp\u003eIt has recently been observed that the risk of recurrent stroke in patients with symptomatic CNO is particularly high during the first two days after the event, and especially in patients with full collapse (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This fact would justify ultra-early revascularization to avoid these early recurrences. In this sense, emergent carotid artery stenting (eCAS), which is increasingly being used in patients with stroke due to tandem occlusion (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), could be considered a good strategy for these patients. However, it is important to note that stent placement in CNO is a technically challenging procedure (especially in cases with full collapse) as it involves crossing a very severe stenosis and expanding the stent in a very narrow artery (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Moreover, in the context of acute stroke the technical difficulty may be even greater and the risk-benefit margin narrower. In this study, revascularization failure rates were similar for CNO and for patients with ICA occlusion or \"conventional\" stenosis (16% and 15%, respectively), and no significant differences were observed between patients with and without full collapse (22% and 12.5% ​​respectively, p\u0026thinsp;=\u0026thinsp;0.368). This result contrasts with previous data in which a higher incidence of revascularization failure was observed in patients with CNO and full collapse (33% compared with 6% in patients without full collapse) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe safety of carotid revascularization in CNO, and especially in CNO with full collapse, remains a matter of debate. A higher incidence of cerebral hyperperfusion syndrome has been reported in patients with CNO undergoing CAS, reaching up to 30% of patients with CNO and full collapse (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A higher rate of perioperative events and post-procedural stroke or death has also been observed in patients with CNO and full collapse (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In our cohort, patients with CNO undergoing eCAS had a higher rate of ICH (37%, 41% in the subgroup of CNO with full collapse versus 23% in all other patients). A previous report by Johansson et al. also observed a high rate of ICH (2 out of 10 cases, one of them fatal) after revascularization of CNO with full collapse patients (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). It has been proposed that flow reduction associated with full collapse and hyperperfusion after revascularization may be involved in the pathophysiology of this phenomenon. In our study, performing carotid revascularisation during the acute stage of stroke may also have increased the risk of hemorrhagic transformation. However, it is important to highlight that despite the observed higher rate of any ICH in CNO patients in our cohort, this did not translate into increased rates of symptomatic ICH or poorer 3-month functional outcomes compared to other groups. This suggests that many of these hemorrhagic events might be of minor clinical significance (e.g., petechial hemorrhages), a finding that could nuance the perception of the procedure's safety profile in this specific population, indicating that the increased ICH risk may not necessarily lead to worse clinical sequelae.\u003c/p\u003e\u003cp\u003eIn this study, we compared the effects of eCAS in patients with CNO and tandem occlusion versus patients with isolated ICA involvement (ie, CNO without intracranial occlusion). We made this distinction because we believe that these are two subgroups with significant differences in the mechanism involved in stroke (embolism in patients with tandem occlusion versus hypoperfusion in patients with isolated ICA involvement) and, therefore, there may be differences in treatment outcomes or complications. We detected no differences between the two groups in the rate of technical failure, nor in functional outcome at 3 months. However, the subgroup with tandem occlusion had a higher rate of ICH. This last finding could be paradoxical considering that post-revascularization hyperperfusion syndrome and higher risk of ICH would be more expected in the group with isolated extracranial ICA involvement. This observation is nevertheless limited by the small number of patients analyzed and should be confirmed in larger cohorts.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, the study only assessed the feasibility and safety of eCAS in patients with CNO and acute stroke, as part of the acute endovascular treatment of these patients. Since there was no control group, the effect of the procedure on recurrence prevention could not be analysed. Second, the analysed data came from a registry of mechanical thrombectomy in acute stroke, not specifically designed to evaluate the effect of eCAS in patients with CNO. Third, the small sample size could have affected the statistical power of the study, limiting the ability to analyse patient subgroups (CNO with FC, isolated extracranial ICA involvement, etc.) and to identify factors associated with the assessed outcomes. Finally, the diagnosis of CNO and FC was not centralized, and therefore diagnostic errors may have occurred, especially \"false\" FC images produced by intracranial occlusions rather than CNO.\u003c/p\u003e\u003cp\u003eIn conclusion, the use of emergent carotid stenting in patients with carotid near-occlusion appears to be feasible, both in patients with ipsilateral acute stroke due to tandem occlusion and those without intracranial occlusion. However, the safety of the procedure is uncertain, as it could be associated with an increased risk of intracerebral hemorrhage. Our results highlight the need for larger studies to establish the safety and usefulness of emergent revascularization therapy in patients with symptomatic carotid near-occlusion.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval\u003c/h2\u003e\u003cp\u003e The Ethics committees of Gregorio Mara\u0026ntilde;\u0026oacute;n University Hospital approved this study (Record #06/2024)\u003c/p\u003e\u003ch2\u003eInformed consent\u003c/strong\u003e\u003cp\u003e informed consent was waived because of the retrospective nature of this study.\u003c/p\u003e\u003ch2\u003eFunding and/or Conflicts of interests/Competing interests\u003c/h2\u003e\u003cp\u003eThe authors declare to have no conflict of interest. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAGP contributed the conception and design of the study; AGP, ILR, ABT, DS, PC, FO, EdC-R, CGE, PS, AL-FL-J, DPG, RVL, CM, JCF-F, MTMM, JRE, AGT, INV, EEE, RTC, GMA, AMIM, MVM and AGN contributed to the acquisition and analysis of data and drafting the text.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJohansson E, Fox A (2016) Carotid Near-Occlusion: A Comprehensive Review, Part 1\u0026mdash; Definition, Terminology, and Diagnosis. AJNR Am J Neuroradiol 37:2\u0026ndash;10\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHenze A, Fox AJ, Johansson E (2024) High risk of early recurrent stroke in patients with near-occlusion with full collapse of the internal carotid artery. Neuroradiology 66(3):349\u0026ndash;352\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWei W, Zhang J, Xie S, Fan D, Chen Y, Zhong C et al (2024) Acute carotid stenting versus non-stenting treatment of acute ischemic stroke due to tandem lesions: a systematic review and meta-analysis. J Neurol 271:5713\u0026ndash;5721\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBartlett ES, Walters TD, Symons PSFA (2006) Diagnosing Carotid Stenosis Near-Occlusion by Using CT Angiography. AJNR Am J Neuroradiol 27:632\u0026ndash;637\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJohansson E, Gu T, Fox AJ (2021) Defining carotid near occlusion with full collapse : a pooled analysis. Neuroradiology 64:59\u0026ndash;67\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHacke W, Kaste M, Bluhmki E, Brozman M, D\u0026aacute;valos A, Guidetti D et al (2008) for the EInvestigators. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. N Engl J Med 359:1317\u0026ndash;1329\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGarcia-Pastor A, Gil-N\u0026uacute;\u0026ntilde;ez A, Ramirez-Moreno JM, Gonz\u0026aacute;lez-Nafr\u0026iacute;a N, Tejada J, Moniche F et al (2022) Endarterectomy, Stenting, or Medical Treatment for Symptomatic Carotid Near-Occlusion: Results from CAOS, a Multicenter Registry Study. Am J Neuroradiol 43(9):1304\u0026ndash;1310\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeves CRB, Casella IB, da Silva ES, Puech-Le\u0026atilde;o P (2018) Medical Therapy for Asymptomatic Patients and Stent Placement for Symptomatic Patients Presenting with Carotid Artery Near-Occlusion with Full Collapse. J Vasc Interv Radiol 29(7):998\u0026ndash;1005\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCay F, Cil BE, Balci S, Arsava EM, Top\u0026ccedil;uoǧlu MA, Arat A (2020) Relevance of distal arterial collapse in stenting of atherosclerotic near-occlusion of the carotid artery. Am J Neuroradiol 41(6):1054\u0026ndash;1060\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePagliariccio G, Di Sario I, Capoccia L, D\u0026rsquo;Elia M, Bafile G, Leopardi M et al (2024) Carotid Near-Occlusion: Surgical or Conservative Management? Retrospective Multicenter Study. Annals of Vascular Surgery. Elsevier Inc., pp 133\u0026ndash;139\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJohansson E, Gu T, Castillo S, Brunstr\u0026ouml;m M, Holsti M, Wanhainen A (2022) Intracerebral Haemorrhage after Revascularisation of Carotid Near Occlusion with Full Collapse. European J Vasc Endovasc Surg [Internet]. ;63:523\u0026ndash;4. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejvs.2021.10.057\u003c/span\u003e\u003cspan address=\"10.1016/j.ejvs.2021.10.057\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7225884/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7225884/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBACKGROUND: The increased very early risk (within the first 2 days after presenting event) of recurrent stroke among patients with symptomatic carotid near-occlusion (SCNO) and full collapse (FC) might justify ultra-early carotid revascularization of these patients. However, we lack data about technical effectiveness and safety of this approach in SCNO. This study aims to assess the feasibility and safety of emergent carotid stenting (eCAS) in patients with SCNO.\u003c/p\u003e\n\u003cp\u003eMETHODS: multicenter study including patients with acute stroke and extracranial carotid stenosis or occlusion undergoing mechanical thrombectomy and eCAS. The main outcomes were revascularization failure (incomplete carotid revascularization/occlusion at 48h), intracerebral hemorrhage (ICH) and symptomatic ICH (sICH). Patients with SCNO with and without FC were compared with the remaining patients.\u003c/p\u003e\n\u003cp\u003eRESULTS: 309 patients were included, 215 (69.6%) males, mean age (SD) 67.2 (12.8). 52 patients had SCNO and 18 SCNO+FC. Revascularization failure occurred in 16% of SCNO and in 15.2% of the remaining patients (p=0.884), with no differences between SCNO with or without FC. ICH was more common in patients with SCNO (37% for all SCNO, 41% for SCNO+FC, and 23% for the remaining patients; p=0.033). This increased risk of ICH associated with SCNO persisted in the multivariate analysis (OR 2.84 [95%CI 1.41 – 5.71], p=0.003). The rate of sICH was identical (6%) for SCNO and the rest of patients.\u003c/p\u003e\n\u003cp\u003eCONCLUSIONS:\u003c/p\u003e\n\u003cp\u003eThe use of eCAS in acute SCNO seems to be feasible. However, the safety of the procedure is uncertain, as it could be associated with an increased risk of ICH.\u003c/p\u003e","manuscriptTitle":"Technical Effectiveness and Safety of Emergent Stenting in Patients With Acute Ischemic Stroke and Carotid Near-Occlusion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-08 16:16:09","doi":"10.21203/rs.3.rs-7225884/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e8441ec4-8ad5-4cf1-bf7f-d751039c6969","owner":[],"postedDate":"August 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:09:12+00:00","versionOfRecord":{"articleIdentity":"rs-7225884","link":"https://doi.org/10.1007/s00234-025-03784-x","journal":{"identity":"neuroradiology","isVorOnly":false,"title":"Neuroradiology"},"publishedOn":"2025-09-30 15:57:38","publishedOnDateReadable":"September 30th, 2025"},"versionCreatedAt":"2025-08-08 16:16:09","video":"","vorDoi":"10.1007/s00234-025-03784-x","vorDoiUrl":"https://doi.org/10.1007/s00234-025-03784-x","workflowStages":[]},"version":"v1","identity":"rs-7225884","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7225884","identity":"rs-7225884","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}