Proximal Internal Carotid Artery Acute Stroke Secondary to Tandem or Local Occlusion Thrombectomy Trial

Inclusion Criteria:

1. 18 to 79 years of age (before the 80th birthday)

2. Presenting with symptoms consistent with AIS

3. Imaging evidence of an anterior circulation occlusion of the Internal Carotid Artery (ICA) terminus and/or Middle Cerebral Artery Main Stem (MCA M1), or proximal M2segment AND extra-cranial proximal carotid occlusion / severe stenosis related toatherosclerosis requiring treatment on non-invasive imaging ≥70%

4. NIHSS ≥ 4

5. Ability to randomize and start endovascular therapy within 16 hours of stroke onset

6. Pre-stroke mRS score 0-2

7. Ability to obtain signed informed consent

8. ASPECTS Score ≥7 via non-contrast CT or MRI (DWI) for subjects ≤6 hours from strokeonset OR ASPECTS Score ≥7 + infarct core volume <50 cc quantified by CTP (rCBF<30%)OR <25 cc quantified by MRI-DWI (AxBxC/2) for subjects with endovascular therapystarting between >6h to 16 hours from stroke onset, given the need for antiplatelettherapy.

9. Acute Neurological Deficit with Imaging evidence of Tandem Lesion: Extracranial carotid occlusion (70% to 100% Using NACET criteria) With or withoutintracranial vascular occlusion

10. Must be ineligible for IV t-PA therapy or have failed IV t-PA therapy

Exclusion Criteria:

1. Females who are pregnant, or those of child-bearing potential with positive urine orserum beta Human Chorionic Gonadotropin (HCG) test

2. Known severe allergy (more than a rash) to contrast media uncontrolled bymedications

3. Refractory hypertension (defined as persistent systolic blood pressure >185 mmHg ordiastolic blood pressure >110 mmHg) despite medication

4. CT evidence of the following conditions:

• Midline shift or herniation

• Evidence of intracranial hemorrhage

• Mass effect with effacement of the ventricles

5. Acute bilateral strokes

6. Contraindication to antiplatelet (Aspirin, Plavix, Ticagrelor, Cangrelor), orthrombolytic therapy, or contrast agents.

7. Intracranial tumors other than small meningioma that does not require surgery forone year post randomization

8. Known hemorrhagic diathesis, coagulation factor deficiency, or on anticoagulanttherapy with an International Normalized Ratio (INR) of >1.7 or PartialThromboplastin Time (PTT) > 3 times of normal

9. Baseline platelet count <100,000 per microliter (μl)

10. Life expectancy less than one year prior to stroke onset

11. Participation in another randomized clinical trial that could confound theevaluation of the study outcomes

12. Any other condition (in the opinion of the site investigator) that precludes anendovascular procedure or poses a significant hazard to the patient if anendovascular procedure was performed

13. Proximal carotid stenosis secondary to dissection or vasculitis (.e.g. Takayasu'sArteritis)