Carotid artery stenting or carotid endarterectomy for residual significant stenosis after thrombectomy in acute tandem occlusion stroke?

A 82-year-old male presented with right-sided hemiplegia and aphasia. CT-scan showed hyperdensity of the left middle cerebral artery (MCA). CT-angiography revealed occlusion of the left MCA and intra-cranial internal carotid artery (ICA) in combination with occlusion of the left extra-cranial ICA. Complete recanalization of intra-cranial vessels was obtained after thrombectomy within 6 h from symptom onset, but residual significant extra-cranial stenosis remained. Non-contrast CT-scan after thrombectomy revealed large hyperdensities secondary to contrast extravasation in the left MCA territory. Residual extra-cranial ICA stenosis was not treated with emergent stenting. At 24 h, NIHSS score was 0, but follow-up CT-scan showed an ischemic lesion with spontaneous hemorrhagic transformation. A single antiplatelet treatment was reintroduced after 24 h and carotid endarterectomy was done without complications after 2 weeks.