Endovascular treatment for cervical internal carotid artery occlusion due to dissection: a multicenter analysis

Evidence on endovascular treatment (EVT) for isolated cervical internal carotid artery occlusion (c-ICA-O) due to dissection is limited. We evaluated the impact of EVT for dissection-related isolated (non-tandem) c-ICA-O. This secondary analysis of the multicenter EVT for Isolated cervical Internal Carotid Artery occlusion (ETIICA) retrospective study included patients with dissections. Patients treated with EVT were compared with those treated with best medical treatment alone. The primary endpoint was 90-day modified Rankin Scale (mRS) shift analysis. Secondary outcomes included mRS 0-2 or return to baseline, early neurological deterioration (END), symptomatic intracerebral hemorrhage (sICH), carotid patency at the end of EVT, and intracranial embolization. Analyses used regressions with inverse probability of treatment weighting. Of 998 patients, 108 (10.8%) had dissection [mean age 53.7 (SD 11.2) years, 26.9% female]. EVT was performed in 60 (55.5%) patients. EVT patients had higher admission NIHSS (median 13 [4-18] vs 2 [0-9]). There was no difference in mRS shift (acOR 0.80, 95% CI: 0.29-2.20). Functional independence was observed in 64.9% of EVT patients vs 81.3% of BMT patients (aOR 1.69, 95% CI: 0.52-5.51; BMT as reference). END was numerically more frequent in the EVT group (28.8% vs 8.3%; aOR 2.38, 95% CI: 0.62-9.18). sICH occurred in 2 EVT patients. Carotid patency was achieved in 45/60 (75%) patients undergoing EVT, and 18/59 (30%) patients had intracranial embolization. In this exploratory analysis, EVT was not associated with improved 3-month functional outcomes, despite achieving carotid patency in three out of four patients. Question What are the technical and clinical outcomes of EVT compared with best medical treatment in patients with isolated cervical internal carotid artery occlusive dissection? Findings EVT effectively recanalized acutely occluded dissected extracranial internal carotid arteries, but intracranial emboli and re-occlusion were frequent, with no adjusted 90-day clinical benefit. Clinical relevance Precaution and technical refinement of EVT for isolated cervical carotid artery dissection appear necessary. Larger studies focusing on severely affected patients are warranted. Until such evidence is available, treatment decisions should be individualized on a case-by-case basis.