Endovascular therapy in patients with acute intracranial non-terminal internal carotid artery occlusion (ICA-I)

Christoph Riegler^{1

2}, Regina von Rennenberg^{1

2}, Kerstin Bollweg^{1

2}, Eberhard Siebert³, Gian Marco de Marchis⁴, Georg Kägi^{4

5}, Pasquale Mordasini⁵, Mirjam R Heldner⁵, Mauro Magoni⁶, Alessandro Pezzini⁷, Alexander Salerno⁸, Patrik Michel⁸, Christoph Globas⁹, Susanne Wegener⁹, Nicolas Martinez-Majander¹⁰, Sami Curtze¹⁰, Maria Luisa Dell'Acqua¹¹, Guido Bigliardi¹¹, Nabila Wali¹², Paul J Nederkoorn¹², Dejana R Jovanovic¹³, Visnja Padjen¹³, Issa Metanis¹⁴, Ronen R Leker¹⁴, Giovanni Bianco¹⁵, Carlo W Cereda¹⁵, Rosario Pascarella¹⁶, Marialuisa Zedde¹⁷, Maria Maddalena Viola¹⁸, Andrea Zini¹⁸, João Nuno Ramos¹⁹, João Pedro Marto²⁰, Heinrich J Audebert^{1

2}, Simon Trüssel^{21

22}, Henrik Gensicke^{21

22}, Stefan T Engelter^{21

22}, Christian H Nolte^{1

2

23

24}

Affiliations

¹ Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
² Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Bern, Germany.
³ Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
⁴ Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland.
⁵ Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
⁶ Department of Neurological Sciences and Vision, ASST Spedali Civili, Brescia, Italy.
⁷ Department of Medicine and Surgery, University of Parma, Stroke Care Program; Department of Emergency, Parma University Hospital, Parma, Italy.
⁸ Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
⁹ Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
¹⁰ Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
¹¹ Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital, Modena, Italy.
¹² Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands.
¹³ Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
¹⁴ Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
¹⁵ Stroke Center and department of Neurology, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland.
¹⁶ Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
¹⁷ Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
¹⁸ IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy.
¹⁹ Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
²⁰ Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
²¹ Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland.
²² Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.
²³ Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.
²⁴ Deutsches Zentrum für Herz-Kreislaufforschung DZHK, Berlin, Germany.

PMID: 39473238
PMCID: PMC11556625
DOI: 10.1177/23969873241278948

Multicenter Study

Endovascular therapy in patients with acute intracranial non-terminal internal carotid artery occlusion (ICA-I)

Christoph Riegler et al. Eur Stroke J. 2025 Jun.

. 2025 Jun;10(2):406-415.

doi: 10.1177/23969873241278948. Epub 2024 Oct 29.

Authors

Affiliations

¹ Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
² Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Bern, Germany.
³ Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
⁴ Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland.
⁵ Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
⁶ Department of Neurological Sciences and Vision, ASST Spedali Civili, Brescia, Italy.
⁷ Department of Medicine and Surgery, University of Parma, Stroke Care Program; Department of Emergency, Parma University Hospital, Parma, Italy.
⁸ Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
⁹ Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
¹⁰ Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
¹¹ Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital, Modena, Italy.
¹² Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands.
¹³ Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
¹⁴ Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
¹⁵ Stroke Center and department of Neurology, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland.
¹⁶ Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
¹⁷ Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
¹⁸ IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy.
¹⁹ Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
²⁰ Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
²¹ Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland.
²² Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.
²³ Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.
²⁴ Deutsches Zentrum für Herz-Kreislaufforschung DZHK, Berlin, Germany.

PMID: 39473238
PMCID: PMC11556625
DOI: 10.1177/23969873241278948

Abstract

Background: Acute intracranial occlusion of the internal carotid artery (ICA) can be distinguished into (a) occlusion of the terminal ICA, involving the proximal segments of the middle or anterior cerebral artery (ICA-L/-T) and (b) non-terminal intracranial occlusions of the ICA with patent circle of Willis (ICA-I). While patients with ICA-L/-T occlusion were included in all randomized controlled trials on endovascular therapy (EVT) in anterior large vessel occlusion, data on EVT in ICA-I occlusion is scarce. We thus aimed to evaluate effectiveness and safety of EVT in ICA-I occlusions in comparison to ICA-L/-T occlusions.

Methods: A large international multicentre cohort was searched for patients with intracranial ICA occlusion treated with EVT between 2014 and 2023. Patients were stratified by ICA occlusion pattern, differentiating ICA-I and ICA-L/-T occlusions. Baseline factors, technical (modified thrombolysis in cerebral infarction (mTICI) scale) and functional outcomes (modified Rankin scale [mRS] at 3 months) as well as rates of (symptomatic) intracranial hemorrhage ([s]ICH) were analyzed.

Results: Of 13,453 patients, 1825 (13.6%) had isolated ICA occlusion. ICA-occlusion pattern was ICA-I in 559 (4.2%) and ICA-L/-T in 1266 (9.4%) patients. Age (years: 74 vs 73), sex (female: 45.8% vs 49.0%) and pre-stroke functional independency (pre-mRS ⩽ 2: 89.9% vs 92.2%) did not differ between the groups. Stroke severity was lower in ICA-I patients (NIHSS at admission: 14 [7-19] vs 17 [13-21] points). EVT was similarly successful with respect to technical (mTICI2b/3: 76.1% (ICA-I) vs 76.6% (ICA-L/-T); aOR 1.01 [0.76-1.35]) and functional outcome (mRS ordinal shift cOR 1.01 [0.83-1.23] in adjusted analyses. Rates of ICH (18.9% vs 34.5%; aOR 0.47 [0.36-0.62] and sICH (4.7% vs 7.3%; aOR 0.58 [0.35-0.97] were lower in ICA-I patients.

Conclusion: EVT might be performed safely and similarly successful in patients with ICA-I occlusions as in patients with ICA-L/-T occlusions.

Keywords: Endovascular therapy; ICA-I Occlusion; ischemic stroke; mechanical thrombectomy.

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Conflict of interest statement

Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RRL received speaker honoraria from IscemaView, Boehringer Ingelheim, Pfizer, Jansen, Biogen, Medtronic and Abott and advisory board honoraria from Jansen and Bayer.STE has received funding for travel or speaker honoraria from Bayer, Boehringer Ingelheim and Daiichi-Sankyo. He has served on scientific advisory boards for Bayer, Boehringer Ingelheim, BMS/Pfizer, and MindMaze and on the editorial board of Stroke. His institutions have received an educational grant from Pfizer, compensation from Stago for educational efforts and research support from Daiichi-Sankyo, the Science Funds [Wissenschaftsfonds] of the University Hospital Basel, the University Basel, from the “Wissenschaftsfonds Rehabilitation” of the University Hospital for Geriatric Medicine Felix Platter, the “Freiwillige Akademische Gesellschaft Basel,” the Swiss Heart Foundation, and the Swiss National Science Foundation.HG has received research support from the Swiss National Science Foundation, advisory board honoraria from Daiichi Sankyo and funding for travel from BMS/Pfizer.AZ received speaker honoraria from CSL Behring, Boehringer-Ingelheim, Alexion-Astra Zeneca and Daiichi Sankyo and advisory board honoraria from Bayer, Astra Zeneca and Daiichi Sankyo.DRJ received speaker honoraria from Medtronic and Boehringer Ingelheim.VP received speaker honoraria from Medtronic and Boehringer Ingelheim.H.J.A. reports receiving personal fees from Astra Zeneca, Boehringer Ingelheim, Novo Nordisk, and Roche that all produce products for hyperacute stroke care.MRH reports grants from SITEM Research Support Funds and Swiss National Science Foundation, Swiss Heart Foundation, not directly related to this manuscript.AS received travel grants from NovoNordiskPM received grants from the Swiss National Science Foundation, the Swiss Heart Foundation, and Faculty of Biology and Medicine of the Lausanne UniversityCHN reports receiving speaker honoraria from Abbot, Alexion, AstraZeneca, Bristol-Meyers Squibb, Pfizer and Takeda, all outside the submitted work.All further authors declare no conflicts of interest related to the presented study.

Figures

**Figure 1.**
Occlusion patterns of the internal carotid artery. ACA: Anterior cerebral artery, MCA: Middle cerebral artery, AcomA: Anterior communicating artery. ICA-I: Occlusion of the non-terminal intracranial segment of the internal carotid artery. ICA-L: Occlusion of the terminal segment of the internal carotid artery (involving the proximal segment of the middle cerebral artery). ICA-T: Occlusion of the terminal segment of the internal carotid artery (involving the proximal segments of the anterior cerebral artery and middle cerebral artery).

**Figure 2.**
Distribution of clinical outcome (mRS) three months after stroke stratified by ICA occlusion pattern. ICA-I: Occlusion of the non-terminal intracranial segment of the internal carotid artery ICA-L/-T: Occlusion of the terminal segment of the internal carotid artery (involving the proximal segment middle cerebral artery (ICA-L) or the proximal segments of the anterior and middle cerebral artery (ICA-T).

See this image and copyright information in PMC

References

1. Berkhemer OA, Fransen PS, Beumer D. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372: 394–420. - PubMed
1. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372: 2296–2306. - PubMed
1. Goyal M, Demchuk A, Menon B, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372: 1019–1030. - PubMed
1. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs.t-PA alone in stroke. N Engl J Med 2015; 372: 2285–2295. - PubMed
1. Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372: 1009–1018. - PubMed

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Endovascular therapy in patients with acute intracranial non-terminal internal carotid artery occlusion (ICA-I)

Affiliations

Endovascular therapy in patients with acute intracranial non-terminal internal carotid artery occlusion (ICA-I)

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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