Impact of cavernous internal carotid artery tortuosity on technical and clinical outcomes in mechanical thrombectomy for acute ischemic stroke: a single-center retrospective study.
Uysal Kocabaş Z, Adıyaman H, Aykaç &, Özdemir A • Frontiers in neurology • 2026
Cavernous ICA tortuosity is an independent predictor of reduced first-pass success and worse early outcomes in mechanical thrombectomy, while aspiration technique and ASPECTS ≥6 were positive predictors of first-pass success.
Key Findings
Results
Cavernous ICA tortuosity was associated with significantly lower first-pass recanalization success compared to non-tortuous anatomy.
First-pass success rate was 43.9% in the tortuous group (Lin III-IV, n=205) versus 54.1% in the non-tortuous group (Lin I-II, n=220); p=0.036
Tortuous anatomy independently reduced first-pass success with OR=0.643 (95% CI: 0.431–0.958; p=0.030) on multivariate logistic regression
Tortuous group required more procedural attempts (median 3 vs. 1; p=0.025)
Fewer patients with tortuous anatomy achieved recanalization within 60 minutes (47.3% vs. 57.3%; p=0.040)
Results
Intracranial hemorrhage was significantly more frequent in patients with cavernous ICA tortuosity.
Intracranial hemorrhage occurred in 35.6% of tortuous patients versus 20.5% of non-tortuous patients (p<0.001)
New territory embolism was also more frequent in the tortuous group (5.4% vs. 1.8%; p=0.048)
These complications were identified as secondary outcomes in the study design
Results
Intra-arterial tPA (IA-tPA) use was significantly higher in patients with tortuous cavernous ICA anatomy.
IA-tPA was used in 21.0% of tortuous patients versus 11.4% of non-tortuous patients (p=0.007)
This likely reflects greater difficulty achieving mechanical recanalization in tortuous anatomy, necessitating adjunctive pharmacologic thrombolysis
Results
Good functional outcome at discharge was significantly lower in the tortuous group.
Good functional outcome (mRS 0–2) at discharge was achieved in 38.5% of tortuous patients versus 55.0% of non-tortuous patients (p=0.001)
Functional outcomes were also assessed at 90 days using the modified Rankin Scale (mRS) as a secondary outcome
The study included 425 total patients with MCA occlusion treated with mechanical thrombectomy at a single center
Results
Aspiration technique and ASPECTS ≥6 were independent positive predictors of first-pass success on multivariate logistic regression.
Aspiration technique was associated with OR=3.682 (p<0.001) for first-pass success
ASPECTS ≥6 was associated with OR=1.566 (p=0.040) for first-pass success
These predictors were identified alongside cavernous tortuosity in the same multivariate logistic regression model
The findings suggest aspiration may be a more effective thrombectomy strategy in patients with tortuous cavernous ICA anatomy
Methods
Patients were classified into tortuous and non-tortuous groups using the Lin grading system based on lateral angiographic assessment.
Tortuous group: Lin grades III–IV (n=205); non-tortuous group: Lin grades I–II (n=220)
Total study population: 425 patients with MCA occlusion treated with mechanical thrombectomy
Design was a single-center retrospective study
Primary outcome was successful recanalization within 60 minutes (puncture-to-recanalization time)
What This Means
This research suggests that the shape of a key blood vessel in the brain — the cavernous portion of the internal carotid artery (ICA) — can significantly affect how well doctors are able to perform mechanical thrombectomy, a procedure used to remove blood clots during a stroke. When this artery has an abnormally winding or tortuous path (classified as Lin grades III–IV), navigating the necessary catheters through it becomes more difficult. Among 425 stroke patients studied, those with tortuous anatomy were less likely to have their clot successfully removed on the first attempt (43.9% vs. 54.1%), took longer to achieve recanalization, and required more procedural attempts.
Patients with tortuous cavernous ICA anatomy also experienced more complications. They had nearly double the rate of intracranial hemorrhage (bleeding in the brain) compared to those with straighter vessels (35.6% vs. 20.5%), more cases of clot material traveling to new areas of the brain (new territory embolism), and more frequent need for additional clot-dissolving medication injected directly into the artery. Importantly, good functional recovery at hospital discharge was substantially lower in the tortuous group (38.5% vs. 55.0%).
This research suggests that a simple pre-procedure assessment of vessel anatomy using standard angiographic imaging could help clinicians identify patients who may face greater procedural challenges. Notably, the use of an aspiration-based thrombectomy technique was a strong predictor of first-pass success, suggesting this approach may be particularly beneficial in patients with tortuous anatomy. These findings highlight the potential importance of tailoring stroke treatment strategies based on individual vascular anatomy.
Uysal Kocabaş Z, Adıyaman H, Aykaç &, Özdemir A. (2026). Impact of cavernous internal carotid artery tortuosity on technical and clinical outcomes in mechanical thrombectomy for acute ischemic stroke: a single-center retrospective study.. Frontiers in neurology. https://doi.org/10.3389/fneur.2026.1867423