PDF: CERES-TANDEM
(2026)Objective
Emergent carotid stenting (eCAS) versus no-stenting during thrombectomy for anterior circulation tandem lesions.
Study Summary
• Higher rates of excellent outcome (mRS 0–1: 29.1% vs 20.2%) with eCAS
• No significant increase in symptomatic intracranial hemorrhage
Intervention
Emergent carotid stenting (eCAS) during endovascular thrombectomy vs no-stenting strategy
Inclusion Criteria
Adults ≥18 years with imaging-confirmed anterior circulation acute ischemic stroke due to tandem lesions (cervical carotid occlusion or >75% stenosis with concurrent intracranial occlusion), undergoing EVT, presenting within 24 hours of symptom onset
Study Design
Arms: eCAS group vs No-stenting group
Patients per Arm: eCAS: 2,522; No-stenting: 1,531
Outcome
• eCAS associated with 3-fold higher successful recanalization (OR 3.09, p<0.001)
• Effect consistent across subgroups regardless of access route, IVT use, sedation type, or occlusion site
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
Study Design
- Study Type
- International multicenter longitudinal retrospective cohort study
- Blinding
- None (retrospective observational study)
- Sample Size
- 4053
- Follow-up
- 90 days
- Centers
- 49
Primary Outcome
Definition: 90-day modified Rankin Scale (mRS) score shift, analyzed using ordinal scale (0–6)
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| Median mRS 4 (IQR 2–5) | Median mRS 3 (IQR 1–4) | - | <0.001 |
Limitations & 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
Citation
Neurology 2026;106:e214528