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El Sayed R, Park CC, Shah Z, Nahab FB, Haussen DC, Allen JW, Oshinski JN. Assessment of Complex Flow Patterns in Patients With Carotid Webs, Patients With Carotid Atherosclerosis, and Healthy Subjects Using 4D Flow MRI. J Magn Reson Imaging 2024; 59:2001-2010. [PMID: 37706274 PMCID: PMC10937327 DOI: 10.1002/jmri.29013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Carotid webs (CaWs) are fibromuscular projections in the internal carotid artery (ICA) that cause mild luminal narrowing (<50%), but may be causative in up to one-third of seemingly cryptogenic strokes. Understanding hemodynamic alterations caused by CaWs is imperative to assessing stroke risk. Time-Average Wall Shear Stress (TAWSS) and Oscillatory Shear Index (OSI) are hemodynamic parameters linked to vascular dysfunction and thrombosis. PURPOSE To test the hypothesis: "CaWs are associated with lower TAWSS and higher OSI than mild atherosclerosis or healthy carotid bifurcation." STUDY TYPE Prospective study. POPULATION A total of 35 subjects (N = 14 bifurcations with CaW, 11F, age: 49 ± 10, 10 mild atherosclerosis 6F, age: 72 ± 9, 11 healthy 9F, age: 42 ± 13). FIELD STRENGTH/SEQUENCE 4D flow/STAR-MATCH/3D TOF/3T MRI, CTA. ASSESSMENT 4D Flow velocity data were analyzed in two ways: 1) 3D ROI in the ICA bulbar segment (complex flow patterns are expected) was used to quantify the regions with low TAWSS and high OSI. 2) 2D planes were placed perpendicular to the centerline of the carotid bifurcation for detailed analysis of TAWSS and OSI. STATISTICAL TESTS Independent-samples Kruskal-Wallis-H test with 0.05 used for statistical significance. RESULTS The percent surface area where low TAWSS was present in the ICA bulb was 12.3 ± 8.0% (95% CI: 7.6-16.9) in CaW subjects, 1.6 ± 1.9% (95% CI: 0.2-2.9) in atherosclerosis, and 8.5 ± 7.7% (95% CI: 3.6-13.4) in healthy subjects, all differences were statistically significant (ƞ2 = 0.3 [95% CI: 0.05-0.5], P-value CaW vs. healthy = 0.2). OSI had similar values in the CCA between groups (ƞ2 = 0.07 [95% CI: 0.0-0.2], P-value = 0.5), but OSI was significantly higher downstream of the bifurcation in CaW subjects compared to atherosclerosis and normal subjects. OSI returned to similar values between groups 1.5 diameters distal to the bifurcation (ƞ2 = 0.03 [95% CI: 0.0-0.2], P-value = 0.7). CONCLUSION Lower TAWSS and higher OSI are present in the ICA bulb in patients with CaW when compared to patients with atherosclerotic or healthy subjects. EVIDENCE LEVEL 2 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Retta El Sayed
- Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, Georgia, USA
- Department of Radiology & Imaging Sciences, Emory University, Atlanta, Georgia, USA
| | - Charlie C. Park
- Department of Radiology & Imaging Sciences, Emory University, Atlanta, Georgia, USA
| | - Zahraw Shah
- Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, Georgia, USA
| | - Fadi B. Nahab
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Diogo C. Haussen
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Jason W. Allen
- Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, Georgia, USA
- Department of Radiology & Imaging Sciences, Emory University, Atlanta, Georgia, USA
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - John N. Oshinski
- Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, Georgia, USA
- Department of Radiology & Imaging Sciences, Emory University, Atlanta, Georgia, USA
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2
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Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Liu W. Floating Thrombosis on a Carotid Web. Neurology 2024; 102:e209311. [PMID: 38560821 DOI: 10.1212/wnl.0000000000209311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Affiliation(s)
- Wei Liu
- From the Department of Neurology, China-Japan Friendship Hospital, Beijing, China
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4
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El Sayed R, Lucas CJ, Cebull HL, Nahab FB, Haussen DC, Allen JW, Oshinski JN. Subjects with carotid webs demonstrate pro-thrombotic hemodynamics compared to subjects with carotid atherosclerosis. Sci Rep 2024; 14:10092. [PMID: 38698141 PMCID: PMC11066020 DOI: 10.1038/s41598-024-60666-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/25/2024] [Indexed: 05/05/2024] Open
Abstract
Carotid artery webs (CaW) are non-atherosclerotic projections into the vascular lumen and have been linked to up to one-third of cryptogenic strokes in younger patients. Determining how CaW affects local hemodynamics is essential for understanding clot formation and stroke risk. Computational fluid dynamics simulations were used to investigate patient-specific hemodynamics in carotid artery bifurcations with CaW, bifurcations with atherosclerotic lesions having a similar degree of lumen narrowing, and with healthy carotid bifurcations. Simulations were conducted using segmented computed tomography angiography geometries with inlet boundary conditions extracted from 2D phase contrast MRI scans. The study included carotid bifurcations with CaW (n = 13), mild atherosclerosis (n = 7), and healthy bifurcation geometries (n = 6). Hemodynamic parameters associated with vascular dysfunction and clot formation, including shear rate, oscillatory shear index (OSI), low velocity, and flow stasis were calculated and compared between the subject groups. Patients with CaW had significantly larger regions containing low shear rate, high OSI, low velocity, and flow stasis in comparison to subjects with mild atherosclerosis or normal bifurcations. These abnormal hemodynamic metrics in patients with CaW are associated with clot formation and vascular dysfunction and suggest that hemodynamic assessment may be a tool to assess stroke risk in these patients.
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Affiliation(s)
- Retta El Sayed
- Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Carissa J Lucas
- Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
| | - Hannah L Cebull
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Fadi B Nahab
- Department of Neurology, Emory University, Atlanta, GA, USA
| | | | - Jason W Allen
- Department of Radiology and Imaging Sciences, Indiana University, Indianapolis, IN, USA
| | - John N Oshinski
- Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA.
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA.
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Arai Y, Cho J, Fujino A, Taira N, Kunieda J, Koike M. Histopathological Examination of a Symptomatic Carotid Web: A Case Report. NMC Case Rep J 2024; 11:69-74. [PMID: 38590927 PMCID: PMC10999461 DOI: 10.2176/jns-nmc.2023-0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/24/2023] [Indexed: 04/10/2024] Open
Abstract
Carotid webs cause ischemic stroke in young people and are associated with a high rate of stroke recurrence. Histopathological examination is crucial for clarifying the pathogenesis and mechanisms underlying the occurrence of carotid webs, although the mechanisms generally remain unclear. Here, we report a case of a symptomatic carotid web in a woman in her 50s who had a medical history of two ischemic strokes. She was diagnosed with a right carotid web and underwent carotid endarterectomy 18 days after the second stroke. Histopathological examination clearly revealed several phases of intimal hyperplasia. Furthermore, a thrombus attached to the carotid web showed invasion by fibroblasts and capillaries, and organization had begun. We presume that after the appearance of the carotid web, the thrombus formed by stagnant flow and became organized, causing the carotid web to grow and change in shape.
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Affiliation(s)
- Yukika Arai
- Department of Neurosurgery, Shuuwa General Hospital, Saitama, Japan
| | - Junshi Cho
- Department of Neurosurgery, Shuuwa General Hospital, Saitama, Japan
| | - Asuka Fujino
- Department of Neurosurgery, Shuuwa General Hospital, Saitama, Japan
| | - Naoki Taira
- Department of Neurosurgery, Shuuwa General Hospital, Saitama, Japan
| | - Junko Kunieda
- Department of Pathology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Morio Koike
- Department of Pathology, Shuuwa General Hospital, Saitama, Japan
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6
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Chung CT, Chen CH, Lin YH, Cheng CJ, Chu HJ, Fu CH, Chen KW, Lee CW, Tang SC, Jeng JS. Prevalence and clinical features of carotid artery web in patients undergoing endovascular thrombectomy for acute ischemic stroke. J Formos Med Assoc 2024:S0929-6646(24)00107-4. [PMID: 38438298 DOI: 10.1016/j.jfma.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 01/20/2024] [Accepted: 02/16/2024] [Indexed: 03/06/2024] Open
Abstract
PURPOSE Carotid artery web (CaW) is a rare focal fibromuscular dysplasia that can lead to embolic strokes with large vessel occlusion. This condition can be effectively treated with endovascular thrombectomy (EVT). Our study aims to assess the prevalence of CaW among patients with acute ischemic stroke (AIS) who underwent EVT and to compare the clinical characteristics of CaW with other carotid artery pathologies. METHODS We enrolled consecutive patients with AIS who underwent EVT at a single medical center and two regional teaching hospitals in Taiwan from September 2014 to December 2021. We compared CaW with carotid dissection (CaD) and carotid large artery atherosclerosis (CaLAA) in terms of patient demographics and thrombus histological findings. RESULTS Of the 576 AIS patients who underwent EVT, four (mean age: 50 years) were diagnosed with CaW, resulting in a prevalence of 0.69%. Among these four patients, three experienced successful reperfusion after EVT and achieved functional independence (defined as a modified Rankin Scale score ≤2) three months post-stroke. Importantly, none of the CaW patients suffered a recurrent stroke within one year. Patients with CaW were younger than those with CaD or CaLAA, and exhibited fewer vascular risk factors. Additionally, CaW was associated with distal occlusion sites. The thrombus composition in CaW patients was similar to that in CaD patients. CONCLUSIONS In conclusion, CaW is a rare finding among Asian patients with carotid artery disease who undergo for AIS. It is more prevalent in younger patients with a limited number of vascular risk factors.
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Affiliation(s)
- Chi-Ting Chung
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Jie Cheng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Hai-Jui Chu
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Chuan-Hsiu Fu
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kuo-Wei Chen
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan.
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Al-Bayati AR, Nogueira RG, Sachdeva R, Mohammaden MH, Bhatt NR, Liberato B, Frankel MR, Haussen DC. Optical Coherence Tomography in the Evaluation of Suspected Carotid Webs. J Neurointerv Surg 2023:jnis-2023-020813. [PMID: 38041658 DOI: 10.1136/jnis-2023-020813] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/25/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Carotid web (CaW) is a subtype of fibromuscular dysplasia that predominantly involves the intimal layer of the arterial wall and is commonly overlooked as a separate causative entity for recurrent strokes. CaW is defined as a shelf-like lesion at the carotid bulb, although different morphological features have been reported. Optical coherence tomography (OCT) has been described in the literature as a useful microscopic and cross-sectional tomographic imaging tool. This study aimed to evaluate the potential utility of OCT in characterizing the wall structure features of patients with suspected CaW. METHODS Retrospective analysis of patients with suspected CaW who underwent digital subtraction angiography (DSA) coupled with OCT of the carotid bulb from 2018 to 2021 in a single comprehensive stroke center. RESULTS Sixteen patients were included. The median age was 56 years (IQR 46-61) and 50% were women. OCT corroborated the diagnosis of CaW in 12/16 (75%) cases and ruled it out in 4/16 (25%) patients in whom atherosclerotic disease was demonstrated. Five of the 12 lesions demonstrated a thick fibrotic ridge consistent with CaW but also showed atherosclerotic changes in the vicinity of the carotid bulb (labeled as "CaW+"). In 4/16 (25%) patients, microthrombi adhered to the vessel wall were noted on OCT (inside the CaW pocket or just distal to the web), none of which were observed on CT angiography or DSA. CONCLUSIONS OCT may have value as a complementary imaging tool in the investigation of patients with suspected CaW and atypical morphological features. Further studies are warranted.
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Affiliation(s)
- Alhamza R Al-Bayati
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
- Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Raul G Nogueira
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
- Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Rajesh Sachdeva
- Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mahmoud H Mohammaden
- Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Nirav R Bhatt
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
- Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Bernardo Liberato
- Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Michael R Frankel
- Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
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Patel SD, Otite FO, Topiwala K, Saber H, Kaneko N, Sussman E, Mehta TD, Tummala R, Hinman J, Nogueira R, Haussen DC, Liebeskind DS, Saver JL. Interventional compared with medical management of symptomatic carotid web: A systematic review. J Stroke Cerebrovasc Dis 2022; 31:106682. [PMID: 35998383 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106682] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/04/2022] [Accepted: 07/20/2022] [Indexed: 10/15/2022] Open
Abstract
BACKGROUND Carotid web (CaW) is non-atheromatous, shelf-like intraluminal projection, generally affecting the posterolateral wall of the proximal internal carotid artery, and associated with embolic stroke, particularly in younger patients without traditional stroke risk factors. Treatment options for symptomatic CaWs include interventional therapy with carotid endarterectomy or carotid stenting versus medical therapy with antiplatelet or anticoagulants. As safety and efficacy of these approaches have been incompletely delineated in small-to-moderate case series, we performed a systematic review of outcomes with interventional and medical management. METHODS Systematic literature search was conducted and data analyzed per PRISMA guidelines (Preferred Reporting Items for Systemic Reviews and Meta-Analyses) from January 2000 to October 2021 using the search strategy: "Carotid web" OR "Carotid shelf" OR "Web vessels" OR "Intraluminal web". Patient-level demographics, stroke risk factors, technical procedure details, medical and interventional management strategies were abstracted across 15 series. All data were analyzed using descriptive statistics. RESULTS Among a total of symptomatic 282 CaW patients across 14 series, age was 49.5 (44-55.7) years, 61.7% were women, and 76.6% were black. Traditional stroke risk factors were less frequent than the other stroke causes, including hypertension in 28.6%, hyperlipidemia 14.6%, DM 7.0%, and smoking 19.8%. Thrombus adherent to CaW was detected on initial imaging in 16.2%. Among 289 symptomatic CaWs across 15 series, interventional management was pursued in 151 (52.2%), carotid artery stenting in 87, and carotid endarterectomy in 64; medical management was pursued in 138 (47.8%), including antiplatelet therapy in 80.4% and anticoagulants in 11.6%. Interventional and medical patients were similar in baseline characteristics. The reported time from index stroke to carotid revascularization was median 14 days (IQR 9.5-44). In the interventional group, no periprocedural mortality was noted, major periprocedural complications occurred in 1/151 (0.5%), and no recurrent ischemic events were observed over follow-up range of 3-60 months. In the medical group, over a follow-up of 2-55 months, the recurrence cerebral ischemia rate was 26.8%. CONCLUSION Cumulative evidence from multiple series suggests that carotid revascularization is a safe and effective option for preventing recurrent ischemic events in patients with symptomatic carotid webs.
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Affiliation(s)
- Smit D Patel
- Neurology Department, UCLA Health, CA, United States.
| | - Fadar Oliver Otite
- Neurology Department, State University of New York Upstate Medical University, Syracuse, United States
| | - Karan Topiwala
- Neurosurgery Department, University in Minnesota, Minneapolis, United States
| | | | - Naoki Kaneko
- Neurology Department, UCLA Health, CA, United States
| | - Eric Sussman
- Neuroradiology Department, Ayer Neuroscience Institute, Hartford Healthcare, CT, United States
| | - Tapan D Mehta
- Neuroradiology Department, Ayer Neuroscience Institute, Hartford Healthcare, CT, United States
| | - Ramachandra Tummala
- Neurosurgery Department, University in Minnesota, Minneapolis, United States
| | - Jason Hinman
- Neurology Department, UCLA Health, CA, United States
| | - Raul Nogueira
- Neurology Department, UPMC Stroke Institute, PA, United States
| | - Diogo C Haussen
- Neurology Department, Grady Memorial Hospital-Atlanta, United States
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9
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Aspegren O, Staessens S, Vandelanotte S, Desender L, Cordonnier C, Puy L, Bricout N, De Meyer SF, Andersson T, Arnberg F. Unusual Histopathological Findings in Mechanically Removed Stroke Thrombi - A Multicenter Experience. Front Neurol 2022; 13:846293. [PMID: 35665052 PMCID: PMC9157388 DOI: 10.3389/fneur.2022.846293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 04/20/2022] [Indexed: 11/20/2022] Open
Abstract
Background Several studies have investigated the histopathology of mechanically retrieved thrombi from stroke patients. Thrombi with unusual components constitute about 1–2% of all stroke thrombi in clinical practice. Knowledge about these rare components is limited. Objectives To characterize the histopathology of unusual stroke thrombi from a real-world setting with relation to clinical presentation, patient characteristics and procedural aspects of mechanical thrombectomy. Methods One-thousand and eight thrombi retrieved from stroke patients with mechanical thrombectomy at three different hospitals were retrospectively reviewed for unusual histological components. Fifteen thrombi were included in the study for further histopathological analysis. Clinical data and data on procedural aspects were collected. Results We identified six cases with large amounts of extracellular DNA, of which three were calcified. All six cases except one received anticoagulant therapy. We describe two types of calcifications that differ with respect to general calcification morphology, von Kossa staining pattern, macrophage immunophenotype and presence of multinucleated giant cells. Cholesterol-rich (n = 3), adipocyte-like pattern-rich (n = 2), collagen-rich (n = 2) and myxomatous (n = 1) thrombi were also identified and are discussed with regard to pathogenesis and clinical and intervention characteristics. Finally, a thrombus with parts of a vascular wall is described. Suggestions for future studies are made and clinical and technical aspects of the management for these rare but important patients are discussed. Conclusion In our retrospective multicenter study, we characterized stroke thrombi histopathologically and found subgroups of thrombi defined by presence of rarely seen components. These defined subgroups showed relation to underlying cardiovascular disease, patient characteristics, and mechanical thrombectomy technique. Knowledge about these components may increase our understanding of stroke pathophysiology and influence interventional procedures.
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Affiliation(s)
- Oskar Aspegren
- Department of Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Sarah Vandelanotte
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Linda Desender
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Charlotte Cordonnier
- University of Lille, INSERM, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Laurent Puy
- University of Lille, INSERM, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, CHU Lille, Lille, France
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Tommy Andersson
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
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10
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Zhou Q, Li R, Feng S, Qu F, Tao C, Hu W, Zhu Y, Liu X. The Value of Contrast-Enhanced Ultrasound in the Evaluation of Carotid Web. Front Neurol 2022; 13:860979. [PMID: 35572949 PMCID: PMC9093455 DOI: 10.3389/fneur.2022.860979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/25/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives The purpose of this study was to investigate whether contrast-enhanced ultrasound (CEUS) is more advantageous than conventional ultrasound in the diagnosis of carotid web (CaW) and to compare the clinical characteristics of patients in different age groups. Methods Seventeen patients admitted to the hospital from October 2019 to December 2021 were included in our study. Patients were initially diagnosed with CaW using digital subtraction angiography (DSA), and conventional ultrasound and CEUS were completed. Baseline patient data were analyzed and compared between the <60 years old CaW group and the ≥60 years old CaW group to explore the differences between the two groups. Then, comparing the accuracy of conventional ultrasound and CEUS. Results A total of 17 CaW patients participated in this study, including 4 female patients (23.5%) and 13 male patients (76.5%), with an average age of 59.41 (±10.86) years. There were 9 patients (52.9%) with left CaW and 8 patients (47.1%) with right CaW. Acute ischemic stroke (AIS) occurred in 14 patients (82.4%). Thrombosis occurred in five of 17 patients (29.4%). There was a significant statistical difference about the thrombosis between the <60 years old CaW group and the ≥60 years old CaW group [<60 years group: 0 (0%), ≥60 years group: 5 (62.5%), P = 0.005]. Seven patients (41.2%) received medical management, nine patients (52.9%) had carotid artery stenting (CAS), and one patient (5.9%) had carotid endarterectomy (CEA). None of the patients had recurrent stroke during the follow-up period. The diagnostic rate of CaW and thrombus by CEUS was higher than that by conventional ultrasound, and there was a significant statistical difference in the diagnosis of thrombus between CEUS and conventional ultrasound (χ2 = 4.286, P = 0.038). Conclusions CEUS may have a higher diagnostic accuracy for CaW with thrombosis, and it has a higher clinical application prospect.
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Zhang J, Yan Y, Yao W, Liu J, Cui L. Multimodality imaging of carotid web: A case report and literature review. Vascular 2022:17085381221084809. [PMID: 35306924 DOI: 10.1177/17085381221084809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The carotid web is a compelling potential mechanism of cryptogenic stroke. It is easy for it to escape diagnosis or be misdiagnosed, since it rarely causes hemodynamic stenosis. Currently, there is a lack of consensus on the prevalence, etiology, imaging evaluation, and treatment strategy of carotid artery. We aimed to present the multimodal imaging of carotid web and comprehensively review the characteristics of carotid web. Methods A 38 year-old man with carotid web, who presented with acute left hemispheric syndrome, was not identified by computed tomography angiography and high-resolution magnetic resonance imaging in the initial report, but were identified in retrospect and then confirmed by digital subtraction angiography and histopathology. A literature review of carotid web was performed to identify prevalence, nature history, imaging tools, and optimal management of carotid web. Results 80 reports including 681 patients with carotid web were identified. The prevalence of symptomatic carotid web was 1.2% in patients with transient ischemic attack/stroke, 6.4% in patients with cryptogenic ischemic stroke, 1.1% in patients with large vessel occlusion stroke, and 4.4% in patients who operated on for carotid stenosis. A total of 23.0% patients had bilateral carotid web. In most patients, carotid web was located on the posterior wall (87.3%) of the carotid artery (98.7%). The mean length was 3.3 mm and mean stenosis rate was 20.9%. A total of 31.6% percent patients had thrombus trapped in carotid web and 75.9% patients had large vessel occlusion. Computed tomography angiography and digital subtraction angiography were favorable tools to detect carotid web. There were rare periprocedural complications and no recurrent strokes in carotid revascularization patients. Conclusions carotid web is an under-recognized cause of ischemic stroke. It is easy to be missed or misdiagnosed. Carotid revascularization can effectively prevent recurrent stroke for patients with symptomatic carotid web. Clinicians should strength their learning and understanding of carotid web.
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Affiliation(s)
- Jie Zhang
- Department of Neurology, First Hospital of Jilin University, Changchun, China
| | - Yuzhu Yan
- Department of Radiology, First Hospital of Jilin University, Changchun, China
| | - Weikai Yao
- Department of Pathology, First Hospital of Jilin University, Changchun, China
| | - Jishuang Liu
- Department of Neurology, First Hospital of Jilin University, Changchun, China
| | - Li Cui
- Department of Neurology, First Hospital of Jilin University, Changchun, China
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Yin J, Wang W, Song Z, Xu Y, Wang Y, Wei Y, Han J. Embolectomy of acute embolic stroke associated with ipsilateral carotid web: a case report and literature review. J Int Med Res 2021; 49:3000605211059929. [PMID: 34842485 PMCID: PMC8649469 DOI: 10.1177/03000605211059929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A carotid web is a thin intraluminal protrusion located in the posterolateral
wall of the carotid bulb, which might be a risk factor for cryptogenic stroke.
The mechanism of ischemic stroke caused by carotid web is still unclear, but it
might be related to hemodynamic changes distal to the web, resulting in flow
forces and remote embolization of fibrin-based clots. The diagnosis of a carotid
web mainly depends on carotid artery imaging examinations. The main therapeutic
strategies include medical treatment with oral antiplatelet agents and
anticoagulants, and operative treatment, such as carotid endarterectomy and
carotid artery stenting. Few cases of acute large-vessel occlusion undergoing
mechanical thrombectomy in the setting of carotid web as the etiology have been
reported. We report here a case of a 37-year-old woman who underwent stent
retriever embolectomy after acute ischemic stroke. Carotid artery imaging
examinations, including digital subtraction angiography and magnetic resonance
imaging, and pathology showed that a carotid web was located at the proximal
right internal carotid artery. We also discuss the clinical pathophysiological
and imaging features, and the treatment of carotid web as described in the
currently available literature.
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Affiliation(s)
- JunTao Yin
- Department of Neurology, 541595Xingtai Third Hospital, Xingtai Third Hospital, Xingtai, China
| | - Wan Wang
- Department of Neurology, Xingtai People's Hospital, Xingtai, China
| | - ZhiJun Song
- Department of Neurosurgery, 541595Xingtai Third Hospital, Xingtai Third Hospital, Xingtai, China
| | - YingDong Xu
- Department of Neurology, 541595Xingtai Third Hospital, Xingtai Third Hospital, Xingtai, China
| | - Yu Wang
- Department of Neurology, 541595Xingtai Third Hospital, Xingtai Third Hospital, Xingtai, China
| | - YuQing Wei
- Department of Neurology, 541595Xingtai Third Hospital, Xingtai Third Hospital, Xingtai, China
| | - Jingzhe Han
- Department of Neurology, Hengshui People's Hospital, Hengshui, Hebei, China
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Haussen DC, Al-Bayati AR, Bhatt N, Nogueira RG. Re: Semerano A, Mamadou Z, Desilles JP, Sabben C, Bacigaluppi M, Piotin M, et al. Carotid webs in large vessel occlusion stroke: Clinical, radiological and thrombus histopathological findings. Journal of the neurological sciences. 2021;427:117550. J Neurol Sci 2021; 429:117620. [PMID: 34438183 DOI: 10.1016/j.jns.2021.117620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/19/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Diogo C Haussen
- Emory University/Marcus Stroke & Neuroscience Center-Grady Memorial Hospital, Atlanta,USA.
| | - Alhamza R Al-Bayati
- Emory University/Marcus Stroke & Neuroscience Center-Grady Memorial Hospital, Atlanta,USA
| | - Nirav Bhatt
- Emory University/Marcus Stroke & Neuroscience Center-Grady Memorial Hospital, Atlanta,USA
| | - Raul G Nogueira
- Emory University/Marcus Stroke & Neuroscience Center-Grady Memorial Hospital, Atlanta,USA
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