This retrospective study evaluated the role of CT angiography (CTA) in distinguishing acute from chronic carotid artery disease in patients with acute ischemic stroke caused by internal carotid artery occlusion. Though often challenging, this distinction is clinically crucial for treatment decisions such as thrombectomy. In this analysis of 42 patients, cases were classified as acute or chronic based on clinical data, treatment outcomes, and infarct patterns. The results showed that acute occlusions were more frequently associated with a tapering pattern, whereas chronic cases showed a stump-like occlusion and a higher atherosclerotic burden in the contralateral carotid artery. A combined imaging score incorporating these features demonstrated excellent diagnostic performance in differentiating acute from chronic disease. Overall, CTA provided reliable imaging markers, particularly occlusion morphology and atherosclerotic burden, that can support more accurate clinical decision-making in this setting.