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CERES-TANDEM

Emergent Carotid Stenting for Acute Anterior Circulation Ischemic Stroke With Tandem Lesions: The Multicenter CERES-TANDEM Study

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Year of Publication: 2026

Authors: Michele Romoli, Carlos A. Molina, Elena Zapata-Arriaza, ..., et al. for CERES-TANDEM

Journal: Neurology

Citation: Neurology 2026;106:e214528

Link: https://www.neurology.org/doi/10.1212/WNL.0000000000214528

PDF: https://www.neurology.org/doi/pdfdirect/...000000000214528

Clinical Question

Does emergent carotid stenting (eCAS) during endovascular thrombectomy (EVT) for anterior circulation tandem lesions improve 90-day functional outcomes compared with a no-stenting strategy?

Bottom Line

In this large real-world cohort, emergent carotid stenting during EVT for anterior circulation tandem lesions was associated with superior 90-day functional recovery (31% higher odds of improvement on mRS) without a significant increase in hemorrhagic risk, supporting consideration of eCAS in clinical practice.

        Major Points
        eCAS was associated with a 31% increase in odds of a 1-point shift toward lower disability on the mRS (cOR 1.31, 95% CI 1.17–1.47, p<0.001)
Higher rates of excellent (mRS 0–1: 29.1% vs 20.2%) and good functional outcomes (mRS 0–2: 47.1% vs 34.9%) in eCAS group
No significant increase in symptomatic intracranial hemorrhage (11.1% vs 9.3%, OR 1.21, p=0.15)
eCAS associated with 3-fold higher successful recanalization rate (90.9% vs 75.9%, OR 3.09, p<0.001)
Effect consistent across multiple subgroups including access route, IVT use, sedation type, and intracranial occlusion site
E-value of 1.95 suggests moderate robustness to unmeasured confounding
Etiology was atherosclerosis in 88% and dissection in 12%; no interaction by etiology

      

Design

Study Type: International multicenter longitudinal retrospective cohort study

Blinding: None (retrospective observational study)

Sample Size: 4053

Centers: 49

Follow-up Duration: 90 days

Inclusion Criteria

Adults ≥18 years at time of stroke
Imaging-confirmed tandem lesion acute ischemic stroke
Cervical carotid occlusion or high-grade stenosis (>75%) on CT or MR-based imaging
Concurrent intracranial arterial occlusion
Undergoing EVT for clot removal
Presentation within 24 hours of symptom onset/last seen well
NIHSS score ≥1
No limitations on baseline functional status, stroke severity, baseline ASPECTS, or tandem occlusion etiology

Exclusion Criteria

No intracranial arterial occlusion
Primary hemorrhagic stroke
Hemorrhagic infarction at time of first imaging
Presentation >24 hours after symptom onset/last seen well
Age <18 years
Posterior circulation tandem occlusion

Outcomes

Outcome	Type	Control	Intervention	HR / OR / RR	P-value
90-day modified Rankin Scale (mRS) score shift, analyzed using ordinal scale (0–6)	Primary	Median mRS 4 (IQR 2–5)	Median mRS 3 (IQR 1–4)		<0.001

Criticisms

Observational retrospective design with potential for unmeasured confounding despite IPTW adjustment
Confounding by indication may persist as eCAS was not pursued in those without full recanalization
Population differs from that included in randomized controlled trials, limiting generalizability
Selection and reporting bias may be present despite longitudinal efforts to ensure data completeness
Heterogeneity in antithrombotic strategies across centers; optimal periprocedural therapy remains undefined
Analysis did not account for late carotid revascularization (>48 hours), potentially underestimating eCAS benefit
Local adjudication of images with potential intrinsic bias
Decision for eCAS, IVT, antithrombotics relied on treating clinicians rather than standardized protocol
More fragile patients and those not referred for EVT were not included
Class II evidence only; confirmation in randomized trials needed

Funding

No targeted funding (investigator-initiated independent study)

Based on: CERES-TANDEM (Neurology, 2026)