ESOC 2026 | When should endovascular therapy be used for isolated extracranial carotid artery occlusion?
Christian Nolte, MD, Charité – Universitätsmedizin, Berlin, Germany, shares guidances for when to use endovascular therapy (EVT) for patients with isolated extracranial carotid artery occlusion. Dr Nolte notes that while some patients can live with an occluded carotid vessel without issues, others may present with sudden neurological deficits, and the decision to intervene with EVT depends on factors such as the location of the occlusion, the severity of the deficit, and the etiology of the stroke. This interview took place at the 12th European Stroke Organisation Conference (ESOC) in Maastricht, The Netherlands.
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Transcript
Isolated internal carotid occlusion is actually a very special scenario because, first of all, you have the circle of Willis, which means that you have collateral flow beyond the occlusion, which means that the occlusion may not be as severe as a more distal occlusion. And second, the internal carotid occlusion is quite a long vessel. It starts at the bifurcation in your neck and goes all the way up to your brain...
Isolated internal carotid occlusion is actually a very special scenario because, first of all, you have the circle of Willis, which means that you have collateral flow beyond the occlusion, which means that the occlusion may not be as severe as a more distal occlusion. And second, the internal carotid occlusion is quite a long vessel. It starts at the bifurcation in your neck and goes all the way up to your brain. So, first of all, it may not be as severe. We have patients that live with an occluded carotid vessel their whole life because collateral flow is perfect and they don’t really have a perfusion problem. But then again there are the other patients that present with a sudden neurological deficit meaning that perfusion of the brain indeed is impaired and we all ask ourselves shouldn’t we open that occluded vessel because obviously it causes a problem. The question is not so easily answered because all the randomized controlled trials we have were only including very distal carotid occlusion, so only those intracranially. Now, if you look at the different segments of the carotid artery, the question may be answered with different answers. A very distal segment is covered by randomized controlled trials and may benefit from EVT. For the other segments of the carotid occlusion, we mainly have observational data. Observational data, as you all know, is prone to bias. When we compare patients with carotid occlusion proximally receiving best medical therapy without endovascular therapy to those receiving endovascular therapy plus medical therapy, the all-over benefit was not shown. So it’s not one-size-fits-all, but you have to differentiate – it’s most likely those really with a severe neurological deficit, those with more distal occlusion, and those – and that’s a very interesting aspect – with embolic etiology, so not those with severe atherosclerosis, because with severe atherosclerosis you also have a high rate of reocclusion of the vessel. So really you have to dig into the matter. It’s not a simple answer but a differentiated one, and to answer your question in a very short sentence, most likely those with more distal occlusions with high neurological deficit and with embolic etiology of the stroke.
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Disclosures
Speaker honoraria from AstraZeneca, Bayer and Pfizer.
