Tandem lesion (cerebrovascular)

Last revised by Rohit Sharma on 15 Feb 2024

Tandem lesion, or tandem occlusion, is a term used in cerebrovascular imaging and intervention to refer to the simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery, in the setting of acute ischemic stroke 1,3

This has implications for endovascular clot retrieval as the proximal lesion needs to be traversed and/or treated before the intracranial thromboembolism retrieved. 

Tandem lesions are encountered in approximately 10-20% of large vessel occlusion cases undergoing endovascular clot retrieval 1,3. As the proximal occlusion is usually due to preexisting atherosclerotic carotid artery stenosis, which is more common in men, the same predilection is seen in tandem lesions 1

The presence of a tandem lesion is generally associated with a poorer prognosis 1. Thrombolysis is less effective than in individuals with isolated intracerebral thromboembolic occlusion 1. Similarly, the added time and complexity of endovascular therapy poses challenges.

In the absence of robust trial data, the consensus is treatment of the carotid artery stenosis with carotid stent placement at the time of endovascular clot retrieval, although this will depend on local preference, equipment and individual patient factors 1,3

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