BACKGROUND:Previous studies have not distinguished patients with acute cervical internal carotid artery (ICA) occlusions from those with intracranial occlusions and often consider them together in the same cohort. OBJECTIVES:To evaluate the outcomes of patients with stroke from acute cervical ICA occlusion treated with intravenous thrombolysis or primary endovascular procedures and to identify early predictors of functional recovery among these patients. DESIGN:Retrospective study. SETTING:Academic hospital. PATIENTS:We studied patients with ischemic stroke who received intravenous thrombolysis or endovascular treatment for acute cervical ICA occlusion at St Mary's Hospital, Mayo Clinic, Rochester, Minnesota. We evaluated the associations of vascular risk factors, severity of stroke, arterial recanalization, presence of tandem occlusions, and collateral distal flow with functional recovery at 90 days after stroke. MAIN OUTCOME MEASURES:Favorable functional recovery (Modified Rankin Scale score, 0-2). RESULTS:We identified 21 patients (median age, 67 years; median National Institutes of Health Stroke Scale score at presentation, 13), of whom 13 patients received intravenous thrombolysis and 8 patients underwent primary endovascular treatment. Three patients who received intravenous thrombolysis underwent rescue endovascular treatment. Favorable functional recovery (Modified Rankin Scale score, 0-2) was observed in 7 patients who received intravenous thrombolysis and in 1 patient who underwent primary endovascular treatment. Good collateral distal flow and intracranial tandem occlusions were observed in 6 patients and 12 patients, respectively. Good collateral distal flow, observed more frequently in cigarette smokers, was associated with favorable functional recovery (odds ratio, 20; 95% CI, 2-242; P = .02). CONCLUSIONS:Intravenous thrombolysis should be administered as first-line treatment in patients with early acute cervical ICA occlusion. Treatment benefits are accentuated in patients with better collateral circulation.