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Introduction Tonsillar loop variants of the cervical internal carotid artery (ICA) pose significant challenges during emergent stroke interventions. In acute ICA occlusions, particularly those involving tandem lesions or dissections, severe tortuosity can obstruct catheter access and increase the risk of procedural complications. A structured escalation strategy is essential to navigate these cases safely and effectively.Aim of Study To define and evaluate a stepwise technical algorithm for ICA access in patients with tonsillar loop anatomy undergoing endovascular thrombectomy for acute large vessel occlusion.Method We retrospectively analysed a series of acute ICA occlusion cases complicated by tonsillar loop anatomy. A four-step escalation strategy was applied. Initial access was attempted using the ‘tightrope technique’ with coaxial microcatheter tracking over a stiff 0.014’ wire. If unsuccessful, a compliant balloon was inflated in the cavernous ICA to straighten the loop. In resistant cases, a stent retriever was deployed to align the axis via pusher tension. If access remained limited, a self-expanding carotid stent was used to permanently straighten the vessel. Each step was selected based on anatomical response and procedural safety.Results In all cases, the escalation strategy enabled successful intracranial access and thrombectomy. No procedural complications occurred.Conclusion Tonsillar loop anatomy in acute ICA occlusion can be safely managed using a structured escalation plan. Familiarity with device behaviour and adaptive strategy sequencing are key to procedural success.Conflict of Interest No