Endovascular straightening of tortuous dissected cervical ICA: a retrospective study in acute stroke

Abstract Purpose Endovascular treatment of acute symptomatic internal carotid artery (ICA) dissection with severe tortuosity can be technically challenging. Conventional anatomy-preserving stenting in highly tortuous anatomy may result in suboptimal stent-wall apposition and acute vessel re-occlusion. We describe an endovascular straightening technique designed to geometrically correct vessel tortuosity and report preliminary experience compared to conventional treatment. Methods This retrospective single-center study included consecutive patients with acute ischemic stroke due to ICA dissection treated endovascularly between 2021 and 2026. Patients received either geometric vessel straightening of the cervical ICA ( n = 15) or conventional anatomy-preserving stenting ( n = 16). Endpoints were acute stent occlusion (≤ 24 h), 90-day functional independence (modified Rankin Scale 0–2), and symptomatic intracranial hemorrhage (sICH). Results Baseline characteristics were balanced between groups. Tandem occlusions were present in 86.7% and 75% of patients, respectively. Acute stent occlusion within 24 h occurred in 1 patient (6.7%) in the straightening group versus 4 patients (25%) in controls ( p = 0.333). At 90 days, functional independence was achieved in 86.7% versus 62.5% (absolute difference 24.2%, p = 0.215). sICH occurred in 0% versus 18.8% ( p = 0.226). All three patients with sICH developed subsequent stent occlusion. Conclusion In this retrospective study, endovascular straightening of severely tortuous dissected cervical ICAs appeared technically feasible, with numerically lower rates of acute stent occlusion and sICH and improved functional independence, though differences were not statistically significant. Given the small sample size, findings should be considered exploratory and hypothesis-generating, warranting prospective, adequately powered validation.