Background: Optimal extracranial management in acute ischemic stroke due to tandem occlusions remains controversial. Balloon-expandable stents used as a bridging strategy with reduced early antiplatelet therapy have been proposed to decrease hemorrhagic risk, but comparative real-world data are limited. Methods: We retrospectively analyzed 268 consecutive patients with tandem lesions treated with mechanical thrombectomy and one of three extracranial strategies: percutaneous transluminal angioplasty (PTA, n = 63), balloon-mounted coronary stenting (n = 56), or self-expanding carotid stenting (n = 149). The primary endpoint was symptomatic intracranial hemorrhage (sICH). Secondary endpoints included hemorrhagic subtypes, reperfusion metrics, re-occlusion, and 90-day functional outcome (mRS). Results: Baseline stroke severity differed among groups, with higher NIHSS scores and larger core volumes in the coronary stent group (p = 0.001). Early antiplatelet therapy within 24 hours also differed significantly (p < 0.001). sICH occurred in 10.1% and did not differ among groups (p = 0.598). Rates of any hemorrhage (p = 0.071), hemorrhagic transformation (p = 0.377), PH1 (p = 0.651), and PH2 (p = 0.813) were comparable, although HT2 was more frequent in the coronary group (p = 0.018). Final TICI grades differed significantly (p < 0.001). Favorable functional outcome (mRS 0–2) at 90 days was highest in the self-expanding stent group (71.1%) compared with PTA (47.6%) and coronary stenting (58.9%) (p = 0.004). However, in multivariable analysis, favorable outcome was independently associated with younger age, lower NIHSS, higher ASPECTS, and complete reperfusion, while extracranial strategy was not independently associated. Re-occlusion rates did not differ (p = 0.250). Conclusions: Extracranial device selection was not associated with differences in symptomatic intracranial hemorrhage despite substantial variability in antiplatelet therapy. Self-expanding stenting was associated with superior functional outcome without increased bleeding risk, supporting individualized management strategies.