Related Experiment Video
Updated: Sep 16, 2025
Author Spotlight: Assessing Ischemic Stroke Damage Through Middle Cerebral Artery Occlusion Model
Published on: August 11, 2023
True versus pseudo-occlusion of the cervical internal carotid artery in acute stroke: A multicenter MR angiography
Christian Heitkamp1, Pia Niederau2,3, Arndt-Hendrik Schievelkamp2
1Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Insights
Differentiating true from pseudo-occlusion of the cervical internal carotid artery (ICA) in stroke patients using contrast-enhanced magnetic resonance angiography (CE-MRA) is feasible. Experienced radiologists demonstrated higher accuracy, aiding optimal treatment selection for endovascular therapy.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Distinguishing true from pseudo-occlusion of the cervical internal carotid artery (ICA) is critical for acute ischemic stroke patients undergoing thrombectomy.
- Pseudo-occlusion is defined as an isolated thrombus in the intracranial ICA that obstructs ascending blood flow.
Purpose of the Study:
- To evaluate the effectiveness of contrast-enhanced magnetic resonance angiography (CE-MRA) in differentiating true from pseudo-occlusion of the cervical ICA.
- To assess the diagnostic performance and reliability of CE-MRA in this clinical context.
Main Methods:
- A multicenter, retrospective analysis included acute ischemic stroke patients with cervical ICA occlusion undergoing thrombectomy.
- CE-MRA images were independently reviewed by radiology fellows and board-certified radiologists.
- Digital subtraction angiography (DSA) served as the reference standard for comparison.
Main Results:
- Of 41 patients, 39% had pseudo-occlusion. Aggregated sensitivity and specificity for CE-MRA were 72% and 86%, respectively.
- Board-certified radiologists achieved higher accuracy with 81% sensitivity and 92% specificity.
- Moderate inter-reader agreement was observed overall (κ=0.48), improving to substantial agreement among experienced radiologists (κ=0.65).
Conclusions:
- CE-MRA is a feasible tool for differentiating true and pseudo-occlusion of the cervical ICA.
- Radiologist experience and training in interpreting specific imaging features are crucial for accurate diagnosis.
- Accurate differentiation aids in selecting appropriate devices for endovascular treatment.
Introduction:
Differentiating true from pseudo-occlusion of the cervical internal carotid artery (ICA) in acute ischemic stroke patients undergoing thrombectomy is crucial but challenging. We aimed to investigate the ability of contrast-enhanced magnetic resonance angiography (CE-MRA) to differentiate true from pseudo-occlusion (defined as an isolated thrombus of the intracranial ICA suppressing ascending blood flow) of the cervical ICA in acute ischemic stroke patients.
Materials And Methods:
Multicenter, retrospective analysis of acute ischemic stroke patients with true or pseudo-occlusion of the cervical ICA and subsequent thrombectomy. Patients with preprocedural CE-MRA showing a lack of contrast filling in the cervical ICA on the symptomatic side were included. Six readers (three radiology fellows and three board-certified radiologists) independently evaluated the CE-MRA images for true or pseudo-occlusion of the cervical ICA using a rating scheme. Their assessments were compared with DSA results as the reference standard. Diagnostic accuracy measures, as well as inter- and intra-reader reliability for detecting pseudo-occlusion, were calculated and compared between subgroups.
Results:
A total of 41 patients were included. The median age was 73 years, and 39% were female. According to the reference standard, 16 of 41 (39%) patients had a pseudo-occlusion of the cervical ICA, while the remainder had a true occlusion. The aggregated sensitivity and specificity from all readers were 72% (95% confidence interval [CI]: 62%-81%) and 86% (95% CI: 79%-91%), respectively. Board-certified radiologists performed better, with a sensitivity of 81% (95% CI: 67%-91%) and specificity of 92% (95% CI: 83%-97%). Overall, inter-reader agreement was moderate (κ = 0.48; 95% CI: 0.31-0.65) and reached substantial agreement within the board-certified radiologists subgroup (κ = 0.65; 95% CI: 0.45-0.85).
Conclusion:
Differentiating true occlusion from pseudo-occlusion of the cervical ICA using CE-MRA is feasible but requires training in specific imaging characteristics as well as experience in interpreting them, as evidenced by the higher diagnostic accuracy of board-certified radiologists. Correct distinction help in optimal material selection (e.g. size and type of guiding catheter) prior to endovascular treatment.
