Researchers from the Sant Pau Research Institute (IR Sant Pau) and the Neurology Department of Hospital de Sant Pau have led a population-based study showing that urgent placement of a carotid stent during thrombectomy improves short- and long-term functional recovery in patients with acute ischemic stroke caused by tandem lesions. This is done without increasing hemorrhagic complications or mortality.
The study, published in Neurology, provides one of the strongest pieces of evidence to date on the role of carotid stenting in the acute management of stroke. Based on a cohort of 578 patients from the population-based Codi Ictus Catalunya registry, the research analyzes real-world practice across ten reference centers performing endovascular treatment in Catalonia between 2017 and 2023, making it both representative and clinically relevant.
Ischemic stroke remains one of the leading causes of death and disability worldwide. Recently, mechanical thrombectomy—a procedure that removes the clot blocking a cerebral artery—has become the treatment of choice for large intracranial artery occlusions. However, between 10% and 20% of patients present with tandem lesions, meaning a simultaneous blockage of the extracranial carotid artery and an intracranial artery. This situation, in addition to representing a particularly severe clinical scenario, poses a complex therapeutic challenge and has sparked debate regarding the safest and most effective revascularization strategy.
Although immediate removal of the intracerebral clot is critical for recovery, urgent treatment of the extracranial carotid artery is less straightforward. On one hand, treating the carotid artery immediately through stent placement may enhance the efficacy of thrombectomy and thus the patient’s functional recovery. On the other hand, the intensive antiplatelet therapy required to keep the stent open may increase the risk of intracerebral hemorrhage, which can be fatal. As a result, no standardized protocols currently exist for the acute treatment of these patients, who have traditionally shown worse recovery rates than other ischemic stroke cases.
The study, coordinated by Dr. Garbiñe Ezcurra-Díaz, researcher in the Cerebrovascular Diseases Group at IR Sant Pau, provides a robust answer to this controversy. The researchers found that immediate carotid revascularization with stenting is associated with better short- and long-term functional outcomes, without increasing hemorrhagic complications or mortality.
Our results show that urgent carotid stenting is not only safe but also consistently improves patients’ long-term functional independence,” explains Dr. Garbiñe Ezcurra-Díaz. “These findings reinforce the importance of considering immediate carotid revascularization in the context of thrombectomy, always within experienced teams and under strict antithrombotic management.”
Furthermore, the positive outcomes were consistent across different clinical profiles, supporting the applicability of the procedure in real-world practice. Functional improvement was even observed in patients with less severe carotid lesions, suggesting that the benefit may not be limited to the most complex cases and that this strategy could be more systematically integrated into acute stroke care for tandem lesions.
Among the 578 patients included in the study, 59.5% were treated with urgent carotid stenting. In this group, outcomes were significantly better both in the acute phase and during follow-up. Patients who received a stent had a 1.5-fold higher likelihood of achieving better functional scores, as measured by the modified Rankin Scale (mRS), at both 90 days and one year after the stroke, compared with those who did not receive a stent.
Similarly, the successful recanalization rate—that is, complete restoration of cerebral blood flow—exceeded 90% among patients treated with urgent stenting, compared with 73% in those who were not. This finding confirms that simultaneous revascularization of both lesions increases the efficacy of endovascular treatment and improves overall cerebral perfusion, a key factor for preserving neuronal tissue and promoting functional recovery.
The study also assessed the impact of antithrombotic therapy on procedural safety. The results indicated that early administration of dual antiplatelet therapy (typically aspirin and clopidogrel) within the first 24 hours after the intervention was associated with lower mortality and better functional outcomes, without a significant increase in symptomatic intracranial hemorrhage. This finding is particularly relevant, as fear of hemorrhagic complications often discourages clinicians from performing urgent carotid stenting during thrombectomy.
According to Dr. Pol Camps, head of the Cerebrovascular Diseases Research Group at IR Sant Pau and senior author of the study, “This work reinforces the safety and efficacy of carotid stenting for the acute treatment of stroke with tandem lesions in real-world clinical practice. It is the largest population-based study conducted to date, providing strong external validity for the results.”
Statistical analyses adjusted for age, sex, and comorbidities confirmed the robustness of the findings, indicating that the benefit of carotid stenting is genuine and independent of other prognostic factors.
The study, named SECURIS (Stenting Extracranial Carotid Artery stenosis dURing endovascular treatment in patients with acute Ischemic Stroke), was developed from the Codi Ictus Catalunya (CICAT) registry, a mandatory population-based registry that prospectively collects all stroke cases treated within the Catalan hospital network. This registry, promoted by the Department of Health of the Government of Catalonia, is an essential tool for assessing healthcare quality and advancing clinical stroke research on a population scale.
The project involved collaboration among the ten reference centers in Catalonia with mechanical thrombectomy capability, including Hospital de Sant Pau, and brought together neurologists and neurointerventionists from across the region. This collaborative approach enabled the analysis of a large, representative cohort of real-world clinical practice, giving the study strong external validity and added value compared with previous, smaller, or single-center investigations.
“Having access to a population-based registry like CICAT allows us to obtain robust evidence on treatment effectiveness and safety under real-world conditions, which is crucial for guiding clinical decision-making and future practice guidelines,” emphasizes Dr. Pol Camps.
The SECURIS results strengthen the case for urgent carotid stenting as a complement to thrombectomy in patients with tandem lesions and open new research avenues. The authors highlight the need for randomized clinical trials to confirm these findings and to explore potential modulating factors of benefit, such as sex or age, since subgroup analysis suggested that the benefit of stenting was less pronounced in women and older patients.
The study also points to the opportunity to optimize antithrombotic protocols following urgent carotid revascularization, as patients treated with early dual antiplatelet therapy showed better outcomes without an increase in bleeding risk.
Ezcurra-Díaz G, Cardona P, Rodriguez-Villatoro N, Doncel-Moriano Cubero A, Flores-Pina B, Figueras-Aguirre GL, Fernández-Pérez I, Xuclà-Ferrarons T, Purroy F, Flores A, Guasch-Jiménez M, Lambea-Gil Á, Prats-Sanchez L, Ramos-Pachón A, Martinez-Domeño A, Marti-Fabregas J, Fernández-Vidal JM, Abilleira S, Salvat-Plana M, Núñez-Guillén A, Lara-Rodríguez B, Rodriguez-Luna D, Hernandez D, Rodríguez Vázquez A, Cabero-Arnold A, Menéndez Albarracín A, Cánovas D, Camps-Renom P. *Emergent carotid artery stenting in patients with acute ischemic stroke with tandem lesions: One-year follow-up results from the SECURIS study.* Neurology 2025;105:e214067. https://doi.org/10.1212/WNL.0000000000214067.
