Early secondary prevention after initially ineffective revascularization treatments for acute ischemic stroke due to tandem occlusion

The most effective treatment of patients with stroke due to tandem occlusion is still unclear. We report the case of a man with stroke due to tandem internal carotid artery/middle cerebral artery occlusion, who underwent initially ineffective intravenous thrombolysis (IVT) and endovascular treatment. Early anticoagulation with apixaban was started after 48 h of IVT, given a newly diagnosed nonvalvular atrial fibrillation. Spontaneous partial recanalization of the cervical internal carotid artery was noted, and carotid endarterectomy was performed 72 h after IVT and 8 h after the last dose of apixaban. Surgery was conducted without any complication and the patient was discharged 7 days after onset with a residual mild hemiparesis. This is the first report of urgent carotid endarterectomy in an anticoagulated patient receiving a direct oral anticoagulant. This case highlights the importance of an early multidisciplinary approach to achieve a successful treatment of stroke due to tandem occlusion. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.