Carotid dissection is a major cause of ischemic stroke in young patients and its endovascular management is complex and lacks consensus. Our aim was to carry out the first comparative evaluation of balloon angioplasty alone versus stenting in the endovascular treatment of acute carotid artery dissection presenting with acute stroke.

From the national ETIS (Endovascular Treatment of Ischemic Stroke) registry, between January 2015 and 2023, we included patients with acute ischemic stroke secondary to internal carotid artery dissection who underwent endovascular treatment. We compared clinical and imaging outcomes at a 3-month follow-up between two endovascular approaches for managing carotid artery dissection: balloon angioplasty alone versus stenting.

Among the 160 patients included, 26 underwent balloon angioplasty alone, and 134 received carotid stenting. At the 3-month follow-up, the distribution of modified Rankin Scale (mRS) scores did not differ significantly between groups (p = 0.73).

Additionally, at 24 hours there were no significant differences observed between the two groups regarding intracranial haemorrhage (31% angioplasty alone vs. 45% stenting; p = 0.202), carotid artery patency immediately after endovascular procedure (38.5% vs 36%, p= 0.826) or at 24 hours (50% vs. 51%; p = 0.9), NIHSS scores (11 ± 8 vs. 11 ± 9; p = 0.972) or emboli in new-territory (11.5% vs. 9%; p = 0.713).

Although infrequently performed, balloon angioplasty alone showed comparable safety and efficacy to stenting and may represent a valid option in selected cases. Nonetheless, the observational design and small sample size warrant caution, and further studies are needed to confirm these findings.