Endovascular treatment in patients with cervical or intracranial isolated internal carotid artery occlusion: A systematic review and meta-analysis

The optimal treatment strategy for isolated internal carotid artery occlusion (IICAO) presenting as acute ischemic stroke (AIS) remains uncertain because these patients were largely excluded from pivotal thrombectomy trials. We compared endovascular treatment (EVT) with best medical treatment (BMT) for IICAO, assessing functional independence, mortality, and safety, and explored outcomes by occlusion site (cervical vs intracranial). Following PRISMA guidelines (PROSPERO CRD420251004624), PubMed, Embase, and Cochrane Library were searched through September 2025. Eligible studies enrolled adults with IICAO treated with EVT or BMT and reported ≥1 predefined outcome: modified Rankin Scale (mRS) 0-2 at 90 days, 90-day mortality, or symptomatic intracranial hemorrhage (sICH). Data were pooled using Mantel-Haenszel random-effects models, reporting odds ratios (ORs) with 95% confidence intervals (CIs). Risk of bias was assessed with ROBINS-I. Five studies including 1531 patients (878 EVT; 653 BMT) met inclusion criteria. EVT patients were younger and had more severe strokes. Pooled analysis showed no significant difference in 90-day functional independence between EVT and BMT (OR 1.78; 95% CI 0.99-3.21; I² = 71%), and adjusted analyses attenuated the effect (OR 1.22; 95% CI 0.82-1.82). No significant differences were found for 90-day mortality (OR 0.84; 95% CI 0.64-1.09; I² = 0%) or sICH (OR 1.48; 95% CI 0.72-3.07; I² = 0%). Subgroup analyses by occlusion site yielded similar neutral results. Current evidence does not demonstrate superiority of EVT over BMT for IICAO, though a possible benefit for intracranial occlusions cannot be excluded. These findings remain hypothesis-generating and emphasize the need for dedicated randomized trials.