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Original research
Diagnostic accuracy of emergency CT angiography for presumed tandem internal carotid artery occlusion before acute endovascular therapy
  1. Marcelo Rocha1,
  2. William T Delfyett2,
  3. Vikas Agarwal2,
  4. Amin Aghaebrahim3,
  5. Ashutosh Jadhav1,
  6. Tudor G Jovin1
  1. 1 Neurology Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  2. 2 Radiology Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  3. 3 Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
  1. Correspondence to Dr Tudor G Jovin, UPMC Stroke Institute, 200 Lothrop Street, Pittsburgh, PA 15213, USA; jovintg{at}


Background Extracranial internal carotid artery (ICA) occlusion can be overestimated on emergent single phase CT angiography (CTA) of stroke patients with isolated intracranial ICA occlusion. We aimed to measure the ability of identifying the extracranial site of presumed tandem ICA occlusions on pre-procedural CTA relative to catheter angiography during acute endovascular stroke therapy.

Methods Retrospective study of patients with intracranial ICA occlusion, with or without extracranial ICA occlusion, who underwent single phase CTA before acute endovascular treatment. Two neuroradiologists reviewed CTA images for the presence or absence of extracranial ICA occlusion, blinded to the catheter angiography results. The sensitivity, specificity, and predictive values of presumed extracranial ICA occlusions on CTA were calculated in reference to catheter angiography.

Results 91 stroke patients with acute intracranial ICA occlusion met the inclusion criteria for the study. 24% of patients (22/91) had tandem ICA occlusion confirmed on catheter angiography. Single phase CTA had a sensitivity of 95.5% (95% CI 77.2 to 99.9%) and a specificity of 69.6% (95% CI 57.3 to 80.1%) for concomitant extracranial ICA occlusion (false positive rate 30.4%). The positive and negative predictive values of single phase CTA for extracranial ICA occlusion in the presence of a distal ICA occlusion were 50% (95% CI 34.2 to 65.8%) and 98% (95% CI 89.1 to 100%), respectively.

Conclusions Emergency single phase CTA is highly sensitive but has reduced specificity to identify extracranial ICA occlusion in patients with intracranial ICA occlusion, which may confound planning for acute endovascular stroke therapy and cause over exclusion of patients with isolated ICA terminus occlusion from clinical trials.

  • ct angiography
  • stroke
  • angiography
  • artery
  • thrombectomy

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  • Contributors Conception and design: MR, WTD, and TGJ. Data acquisition: all authors. Drafting the article: MR and TGJ. Critically revising the article: all authors. Final approval of the version to be published: all authors. Agreement of accountability for all aspects of the work: all authors.

  • Competing interests TGJ reports grant, non-financial, and other support from Neuravi (steering committee-modest), Codman Neurovascular (DSMB-modest), Stryker Neurovascular (PI DAWN-unpaid), and Fundacio Ictus (PI REVASCAT unpaid). Stock: Anaconda, Silk Road, Blockade Medical, Route 92, and FreeOx (modest).

  • Ethics approval The study was approved by the institutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.