Tandem lesions: antithrombotics during thrombectomy linked with worse outcome

Design

Post hoc analysis of a randomised trial (MR CLEAN-MED)

Population

100 thrombectomy patients with carotid tandem lesions

Primary outcome

mRS 0–2 at 90 days; symptomatic intracranial haemorrhage

Effect

mRS 0–2: 34.2% vs 60.9%, aOR 0.79 (0.63–0.99); sICH 15.8% vs 4.4%

A post hoc analysis of the MR CLEAN-MED trial, in BMJ Open (21 September), looked at 100 patients having endovascular thrombectomy who had a carotid tandem lesion — an extracranial carotid stenosis of at least 50% or occlusion alongside an intracranial large-vessel occlusion. It compared patients given periprocedural aspirin, heparin or both with those given neither.

Good functional outcome (modified Rankin 0–2 at 90 days) was reached by 34.2% with antithrombotics versus 60.9% without (adjusted OR 0.79, 95% CI 0.63–0.99). Symptomatic intracranial haemorrhage occurred in 15.8% versus 4.4% (OR 4.31, 95% CI 0.53–35.0), a difference too imprecise to call. Rates were similar whichever agent was used.

Tandem lesions often tempt teams to give antithrombotics, especially when a carotid stent is placed. This small subgroup does not settle the question, but it gives no support to routine periprocedural antithrombotics when no stent is placed.

• Make the antithrombotic decision explicit in the thrombectomy plan, not by default
• Weigh stent placement separately — a carotid stent generally needs antiplatelet cover
• Image for haemorrhage early if antithrombotics were given
• Enrol eligible patients in ongoing tandem-lesion trials where available

Why it matters

It questions a common reflex to add antithrombotics during thrombectomy for tandem lesions.

Don't overread it

A post hoc subgroup of 100 patients cannot establish harm; the haemorrhage difference was not statistically significant.

The statistics, in plain English

The functional-outcome interval just excludes 1, so the association is borderline. The haemorrhage interval runs from 0.53 to 35, meaning the data are compatible with anything from less harm to far more. With 100 patients split into several groups, post hoc findings like this generate hypotheses rather than answers.

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