What does a CTA (Computed Tomography Angiography) showing no acute intracranial findings, no targetable large vessel occlusion, and a patulous upper esophagus indicate?

CTA Results Interpretation: No Acute Stroke Requiring Intervention

These CTA findings indicate no acute stroke requiring emergency intervention—specifically, no large vessel occlusion amenable to mechanical thrombectomy and no acute intracranial pathology requiring immediate treatment. 1

What "No Targetable Large Vessel Occlusion" Means

This is the most clinically significant finding—it rules out occlusions of major intracranial arteries (internal carotid artery, M1/M2 segments of middle cerebral artery, basilar artery) that would require endovascular thrombectomy. 1, 2

• CTA has excellent diagnostic accuracy for detecting large vessel occlusions, with sensitivity of 92-100% and specificity of 82-100% for intracranial occlusions 1
• The absence of large vessel occlusion significantly impacts treatment decisions—patients without large vessel occlusion are not candidates for mechanical thrombectomy 1
• This finding does NOT exclude smaller vessel occlusions (M3 branches, small perforators) or early ischemic changes that may not yet be visible 1

Important caveat: CTA can miss M2 segment occlusions in up to 20% of cases, particularly when interpreted by non-neuroradiologists, and calcified emboli can be overlooked 3

What "No Acute Intracranial Findings" Means

This indicates:

• No acute hemorrhage (intracerebral, subarachnoid, subdural, or epidural) 2
• No early signs of large territorial infarction visible on the CT images 1
• No mass effect, midline shift, or other acute structural abnormalities 2

Critical limitation: Early ischemic changes may not be visible on CT within the first 3-6 hours of stroke onset, as CT has only 61% sensitivity for acute ischemia compared to MRI's 91% 2

The Patulous Upper Esophagus Finding

This is an incidental finding unrelated to stroke evaluation and represents dilation of the upper esophagus. This can be:

• A normal variant in some patients
• Related to esophageal motility disorders (achalasia, scleroderma)
• Associated with chronic gastroesophageal reflux
• Secondary to mechanical obstruction below

This finding requires no acute intervention but may warrant outpatient gastroenterology evaluation if the patient has dysphagia, reflux symptoms, or other esophageal complaints.

Clinical Implications and Next Steps

If stroke symptoms are present despite negative CTA:

• Consider MRI with diffusion-weighted imaging, which detects 91% of acute ischemic strokes versus CT's 61% sensitivity 2
• Small vessel (lacunar) strokes, posterior circulation strokes, and brainstem infarcts are frequently missed on CT but visible on MRI 1
• Patients may still be candidates for IV thrombolysis (tPA) within 4.5 hours if clinical stroke syndrome is present 1, 2

If no stroke symptoms are present:

• These findings represent normal vascular imaging
• No acute intervention is needed
• The esophageal finding can be addressed non-urgently if symptomatic

Common pitfall to avoid: Do not assume "negative CTA" means "no stroke"—CTA primarily evaluates large vessels and may miss small vessel disease, early ischemic changes, and posterior circulation pathology 2, 3