Purpose To evaluate the safety and efficacy of emergency carotid stenting and recanalization using the modified Penumbra System (PS) technique for cases of acute extracranial internal carotid artery (ICA) occlusion and massive thrombus with acute ischemic stroke symptoms.

Methods The clinical outcomes of patients with tandem occlusion of the ICA and middle cerebral artery (MCA) who underwent recanalization by a modified PS technique after carotid artery stenting during the period December 2009 to June 2011 were reviewed.

Results Five patients with tandem occlusion of the ICA and MCA were enrolled. The mean National Institute of Health Stroke Scale (NIHSS) score on admission was 13 (range 9–18). The median time from symptom onset to arrival at hospital was 260 min. The median time lag between arrival at hospital and intra-arterial administration was 70 min. Recanalization by stenting of carotid artery occlusion was successfully performed in all patients. The mean number of recanalizations using the modified PS technique for distally migrated thrombus was 3. Complete recanalization of the MCA was observed in all patients. Symptomatic hemorrhage transformation did not occur during the hospital stay in any of the subjects. At discharge, the mean NIHSS score was 2.2 (range 1–6). At the 3-month follow-up the modified Rankin Scale was excellent in three of the five patients, good in one patient and poor in one patient.

Conclusions The modified PS technique after carotid artery stenting is a safe and effective treatment for patients with a massive thrombus extending into the distal portion of the ICA and a tandem occlusion of the ICA and MCA.