{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T14:44:34Z","timestamp":1777041874230,"version":"3.51.4"},"reference-count":30,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T00:00:00Z","timestamp":1776988800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background\/Objectives: There is no consensus on standardized treatment algorithms for patients with acute ischemic stroke due to anterior circulation tandem occlusions. This study evaluated the outcomes of mechanical thrombectomy and carotid artery stenting in such patients, with a particular focus on a standardized, adaptive, and escalating antithrombotic strategy. Methods: This single-center retrospective study included patients with atherosclerotic tandem occlusion treated between January 2019 and July 2023 at our comprehensive stroke center. All patients underwent mechanical thrombectomy and carotid artery stenting and received a standardized antithrombotic regimen, including the administration of the GPIIb\/IIIa antagonist eptifibatide as rescue therapy. Results: Sixty-seven patients were included in the analysis. Thirty-five patients (52.2%) received eptifibatide due to acute stent thrombosis. Subtotal to total revascularization (mTICI 2b-3) was achieved in 98.5% of patients. The carotid artery reocclusion rate was 3.4% at discharge. Symptomatic intracranial hemorrhage occurred more frequently in patients treated with eptifibatide (9.0% vs. 0%, p = 0.021) but was not associated with mortality or favorable outcome (mRS 0\u20132) at 90 days. In univariable regression analysis, eptifibatide administration was not significantly associated with symptomatic intracranial hemorrhage (OR 1.9, 95% CI 0.3\u201311.4; p = 0.465). Older age was associated with mortality. Conclusions: Our adaptive antithrombotic protocol demonstrated high revascularization and low carotid reocclusion rates. Rescue use of eptifibatide was not significantly associated with symptomatic intracranial hemorrhage; however, a clinically relevant risk cannot be excluded. These findings highlight the importance of tailored antithrombotic strategies in acute ischemic stroke to maintain stent patency while minimizing hemorrhagic complications.<\/jats:p>","DOI":"10.3390\/diagnostics16091281","type":"journal-article","created":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T12:29:11Z","timestamp":1777033751000},"page":"1281","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Adaptive Antithrombotic Strategy for Tandem Occlusion Stroke: Escalating Therapy After Thrombectomy and Stenting"],"prefix":"10.3390","volume":"16","author":[{"given":"Gregory","family":"Howaldt","sequence":"first","affiliation":[{"name":"Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mara","family":"Thut","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0635-358X","authenticated-orcid":false,"given":"Miklos","family":"Krepuska","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patrick","family":"Thurner","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jawid","family":"Madjidyar","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anna","family":"Kyselyova","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Susanne","family":"Wegener","sequence":"additional","affiliation":[{"name":"Department of Neurology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2355-1150","authenticated-orcid":false,"given":"Christoph","family":"Globas","sequence":"additional","affiliation":[{"name":"Department of Neurology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andreas","family":"Luft","sequence":"additional","affiliation":[{"name":"Department of Neurology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland"},{"name":"Cerneo Center for Neurology and Rehabilitation, Seestrasse 18, 6354 Vitznau, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tilman","family":"Schubert","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3750-1100","authenticated-orcid":false,"given":"Lars","family":"Michels","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6805-5150","authenticated-orcid":false,"given":"Zsolt","family":"Kulcsar","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Zhu, F., Bracard, S., Anxionnat, R., Derelle, A.L., Tonnelet, R., Liao, L., Mione, G., Humbertjean, L., Lacour, J.C., and Hossu, G. (2019). Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Strokes Treated by Thrombectomy: A Review of the TITAN Collaboration. Front. Neurol., 10.","DOI":"10.3389\/fneur.2019.00206"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"869","DOI":"10.1161\/01.STR.0000160007.57787.4c","article-title":"Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery\/middle cerebral artery occlusion and isolated middle cerebral artery occlusion","volume":"36","author":"Kim","year":"2005","journal-title":"Stroke"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1723","DOI":"10.1016\/S0140-6736(16)00163-X","article-title":"Endovascular thrombectomy after large-vessel ischaemic stroke: A meta-analysis of individual patient data from five randomised trials","volume":"387","author":"Goyal","year":"2016","journal-title":"Lancet"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1142","DOI":"10.3174\/ajnr.A6582","article-title":"Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions","volume":"41","author":"Poppe","year":"2020","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1007\/s00330-016-4338-y","article-title":"Stent-Retriever Thrombectomy for Acute Anterior Ischemic Stroke with Tandem Occlusion: A Systematic Review and Meta-Analysis","volume":"27","author":"Gory","year":"2017","journal-title":"Eur. Radiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1159\/000367988","article-title":"Antithrombotic therapy in carotid artery stenosis: An update","volume":"73","author":"Paciaroni","year":"2015","journal-title":"Eur. Neurol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1572","DOI":"10.1161\/01.STR.0000221298.43117.be","article-title":"The role of antiplatelet therapy in carotid stenting for ischemic stroke prevention","volume":"37","author":"Chaturvedi","year":"2006","journal-title":"Stroke"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1254","DOI":"10.1161\/STROKEAHA.118.023758","article-title":"Lack of Consensus Among Stroke Experts on the Optimal Management of Patients with Acute Tandem Occlusion","volume":"50","author":"Jacquin","year":"2019","journal-title":"Stroke"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2274","DOI":"10.3174\/ajnr.A6888","article-title":"Considerations for Antiplatelet Management of Carotid Stenting in the Setting of Mechanical Thrombectomy: A Delphi Consensus Statement","volume":"41","author":"Goyal","year":"2020","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1177\/2396987319832140","article-title":"European Stroke Organisation (ESO)\u2014European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE)","volume":"4","author":"Turc","year":"2019","journal-title":"Eur. Stroke J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2250","DOI":"10.1161\/STROKEAHA.118.024733","article-title":"Emergent Carotid Stenting Plus Thrombectomy After Thrombolysis in Tandem Strokes: Analysis of the TITAN Registry","volume":"50","author":"Anadani","year":"2019","journal-title":"Stroke"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1245","DOI":"10.1016\/S0140-6736(98)08020-9","article-title":"Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators","volume":"352","author":"Hacke","year":"1998","journal-title":"Lancet"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1161\/CIRCINTERVENTIONS.112.000093","article-title":"Risk factors for cerebral embolization after carotid artery stenting with embolic protection: A diffusion-weighted magnetic resonance imaging study in 837 consecutive patients","volume":"6","author":"Bijuklic","year":"2013","journal-title":"Circ. Cardiovasc. Interv."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"952","DOI":"10.1016\/j.jvs.2018.09.053","article-title":"Overview of evidence on risk factors and early management of acute carotid stent thrombosis during the last two decades","volume":"69","author":"Coelho","year":"2019","journal-title":"J. Vasc. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"558","DOI":"10.1007\/s11239-022-02688-4","article-title":"Predictors of symptomatic intracranial hemorrhage after endovascular treatment for acute large vessel occlusion: Data from ANGEL-ACT registry","volume":"54","author":"Sun","year":"2022","journal-title":"J. Thromb. Thrombolysis"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1177\/1747493016677842","article-title":"Does prior antiplatelet treatment improve functional outcome after intra-arterial treatment for acute ischemic stroke?","volume":"12","author":"Mulder","year":"2017","journal-title":"Int. J. Stroke"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e248","DOI":"10.1136\/jnis-2022-019527","article-title":"Aspirin versus aggressive antiplatelet therapy for acute carotid stenting plus thrombectomy in tandem occlusions: ETIS Registry results","volume":"15","author":"Marnat","year":"2023","journal-title":"J. Neurointerv. Surg."},{"key":"ref_18","first-page":"15910199231175375","article-title":"Acute carotid stenting plus aspirin during thrombectomy of tandem occlusions: A matched case-control study","volume":"31","author":"Yahia","year":"2023","journal-title":"Interv. Neuroradiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.atherosclerosis.2020.09.002","article-title":"Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance","volume":"313","author":"Blasco","year":"2020","journal-title":"Atherosclerosis"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e388","DOI":"10.1136\/jnis-2022-019875","article-title":"Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: A multicenter study","volume":"15","author":"Pop","year":"2023","journal-title":"J. Neurointerv. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2171","DOI":"10.1161\/STROKEAHA.116.015965","article-title":"Acute Occlusions of Dual-Layer Carotid Stents After Endovascular Emergency Treatment of Tandem Lesions","volume":"48","author":"Yilmaz","year":"2017","journal-title":"Stroke"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.1007\/s00270-022-03200-4","article-title":"Comparison of Restenosis Risk in Single-Layer versus Dual-Layer Carotid Stents: A Duplex Ultrasound Evaluation","volume":"45","year":"2022","journal-title":"Cardiovasc. Intervent Radiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1161\/STROKEAHA.122.039797","article-title":"24-Hour Carotid Stent Patency and Outcomes After Endovascular Therapy: A Multicenter Study","volume":"54","author":"Allard","year":"2023","journal-title":"Stroke"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"3097","DOI":"10.1161\/STROKEAHA.120.033032","article-title":"Endovascular Therapy of Anterior Circulation Tandem Occlusions: Pooled Analysis From the TITAN and ETIS Registries","volume":"52","author":"Anadani","year":"2021","journal-title":"Stroke"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"108560","DOI":"10.1016\/j.clineuro.2024.108560","article-title":"Reevaluating the role of heparin during mechanical thrombectomy for acute ischemic stroke: Increased risks without functional benefit","volume":"246","author":"Jazayeri","year":"2024","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1522","DOI":"10.1161\/STROKEAHA.119.028231","article-title":"Impact of Antiplatelet Therapy During Endovascular Therapy for Tandem Occlusions: A Collaborative Pooled Analysis","volume":"51","author":"Zhu","year":"2020","journal-title":"Stroke"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"693","DOI":"10.1111\/ene.13577","article-title":"Thrombectomy outcomes for acute stroke patients with anterior circulation tandem lesions: A clinical registry and an update of a systematic review with meta-analysis","volume":"25","author":"Tau","year":"2018","journal-title":"Eur. J. Neurol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"107248","DOI":"10.1016\/j.jstrokecerebrovasdis.2023.107248","article-title":"Impact of age on mechanical thrombectomy and clinical outcome in patients with acute ischemic stroke","volume":"32","author":"Rhiner","year":"2023","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1290","DOI":"10.1016\/j.jcin.2018.05.036","article-title":"Carotid Stenting with Antithrombotic Agents and Intracranial Thrombectomy Leads to the Highest Recanalization Rate in Patients with Acute Stroke with Tandem Lesions","volume":"11","author":"Papanagiotou","year":"2018","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"828","DOI":"10.1136\/neurintsurg-2017-013532","article-title":"Antiplatelet pretreatment and outcomes following mechanical thrombectomy for emergent large vessel occlusion strokes","volume":"10","author":"Pandhi","year":"2018","journal-title":"J. Neurointerv. Surg."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/9\/1281\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T12:45:36Z","timestamp":1777034736000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/9\/1281"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,24]]},"references-count":30,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["diagnostics16091281"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics16091281","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,24]]}}}