Interventional compared with medical management of symptomatic carotid web: A systematic review

Treatment of Symptomatic Carotid Webs: A Single-Center Review

BACKGROUND

Carotid webs are abnormal thin shelf-like or flap-like tissue in the carotid bulb (proximal internal carotid artery). Rarely are carotid webs detected prior to symptoms since routine carotid artery surveillance is not performed in younger individuals without traditional risk factors for carotid disease. The cause and natural history remain unknown. In general, they are not common but should be considered in the differential diagnosis of a patient who presents with ischemic neurologic symptoms. The web can create a flow disturbance, potentiating local thrombus formation, which can embolize producing resulting in cerebral ischemia. Current treatment is to reduce thrombus formation (antithrombotics and/or anticoagulation) or to alter the flow disturbance caused by the web (surgical removal or stent).

METHODS

We retrospectively identified all patients presenting with acute ischemic stroke to our Comprehensive Stroke Center that were diagnosed with carotid web from January 2020 to December 2023. Patient demographics, presentation, hospital course including treatment and complications were collected and reported.

RESULTS

Fifteen patients presented with carotid web and stroke from 2020 to 2023 and 13 underwent carotid artery stenting or endarterectomy with no periprocedural complications. Most (40%) carotid webs were not primarily identified by the initial radiology interpretation.

CONCLUSIONS

We discuss our experience of carotid web and its management as well as review of the current literature.

In-hospital recurrent stroke in ipsilateral carotid web patients undergoing thrombectomy

OBJECTIVE

Carotid artery web is a possible cause of ischemic stroke, especially in young patients who lack conventional risk factors. The immediate and long-term outcomes are not well studied. We aimed to determine the association between an ipsilateral carotid web and in-hospital stroke recurrence.

METHODS

We analyzed data from adult patients admitted with an acute anterior circulation large vessel occlusion at a Comprehensive Stroke Center between July 2015 and March 2023. The primary outcome was in-hospital stroke recurrence and secondary outcome was in-hospital recurrent LVO. Multivariable logistic regression was performed to examine the association between ipsilateral carotid web and recurrent ischemic stroke and recurrent LVO.

RESULTS

Of the 1463 patients with anterior circulation large vessel occlusion, 27 (1.8%) had an ipsilateral carotid artery web. Patients with carotid web were younger (median age (IQR), 60 years (53-67 years) versus 74 years (62-84 years), P < 0.01) and less likely to be Caucasian (60% vs. 80%, p = 0.014). Of the 27 patients with carotid web, 18 (70%) had no identifiable competing stroke mechanism. When compared to patients without ipsilateral carotid web, those with an ipsilateral carotid web had a higher risk of recurrent ischemic stroke (adjusted RR: 4.38, 95% CI: 1.38-13.85) and recurrent ipsilateral large vessel occlusion (adjusted RR: 4.49, 95% CI: 1.41-14.21).

INTERPRETATION

Carotid webs are an under recognized cause of acute large vessel occlusion and are associated with higher risk of early recurrence. Studies are needed to validate our findings and test early revascularization strategies in patients with symptomatic carotid artery webs.

Prevalence and clinical features of carotid artery web in patients undergoing endovascular thrombectomy for acute ischemic stroke

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.

Breakthrough of dual-phase CT angiography features of carotid web and its correlation with ischemic stroke

PURPOSE

To investigate the diagnostic value of dual phase CT angiography (CTA) in carotid web and its correlation with ischemic stroke.

METHODS

The imaging data of 726 patients with cervical CTA from January 2015 to November 2019 in Taizhou People's hospital were retrospectively and consecutively analyzed. A total of 16 patients with 23 carotid webs were obtained. The location, morphology and clinical data of 16 patients were observed. Carotid web was identified by two experienced radioimaging experts according to the characteristics of a thin intraluminal filling defect along the posterior wall of the carotid bulb on sagittal CTA and a septum structure in arteries on axial CTA.

RESULTS

In the arterial phase, 23 carotid webs in 16 patients showed membrane like separation in the lumen of the posterior wall of the carotid bulb, and one web extended into the internal and external carotid arteries in a "Y" shape. There were 9 males and 7 females. In venous phase, 16 carotid webs showed linear enhancement, and 15 sites showed delayed emptying of contrast medium at the lateral margin. Five patients were acute or chronic ischemic stroke. The kappa coefficient for interobserver agreement in diagnosing carotid web was 0.79.

CONCLUSION

Dual-phase CTA is effective and reliable method to identifying carotid webs, which may be associated with ischemic stroke.

Carotid webs: a review of pathophysiology, diagnostic findings, and treatment options

A carotid web (CaW) is an atypical form of fibromuscular dysplasia characterized by a fibrous, shelf-like intimal flap originating from the posterior wall of the internal carotid bulb projecting into the arterial lumen. CaWs disturb normal blood flow and create stasis between the intimal reflection and the carotid wall, thereby promoting thrombogenesis and increasing the risk of downstream embolic strokes. Observational data have suggested that CaWs are associated with strokes with otherwise unknown etiology, particularly in young patients without other stroke factors, and stroke recurrence rates of symptomatic CaWs have been reported to be as high as 20% over 2 years. Despite its clinical importance, there are currently no clear guidelines on the management of CaWs. In this narrative review, we discuss the epidemiology, pathogenesis, pathophysiology, diagnosis, and treatment options for this under-recognized entity.

Symptomatic carotid webs require aggressive intervention

OBJECTIVE

Carotid web (CaWeb) is a rare form of fibromuscular dysplasia that can produce embolic stroke. Misdiagnosis of symptomatic CaWeb as "cryptogenic stroke" or "embolic stroke of unknown source" is common and can lead to recurrent, catastrophic neurologic events. Reports of CaWeb in the literature are scarce, and their natural history is poorly understood. Appropriate management remains controversial.

METHODS

CaWeb was defined as a single, shelf-like, linear projection in the posterolateral carotid bulb causing a filling defect on computed tomography angiography (CTA) or cerebral angiography. Cases of symptomatic CaWeb at a single institution with a high-volume stroke center were identified through collaborative evaluation by vascular neurologists and vascular surgeons.

RESULTS

Fifty-two patients with symptomatic CaWeb were identified during a 6-year period (2016-2022). Average age was 49 years (range, 29-73 years), 35 of 52 (67%) were African American, and 18 of 52 (35%) were African American women under age 50. Patients initially presented with stroke (47/52; 90%) or transient ischemic attack (5/52; 10%). Stenosis was <50% in 49 of 52 patients (94%) based on NASCET criteria, and 0 of 52 (0%) CaWebs were identified with carotid duplex. Definitive diagnosis was made by CTA examined in multiple planes or cerebral angiography examined in a lateral projection to adequately assess the posterolateral carotid bulb, where 52 of 52 (100%) of CaWebs were seen. Early in our institutional experience, 10 of 52 patients (19%) with symptomatic CaWeb were managed initially with dual antiplatelet and statin therapy or systemic anticoagulation; all suffered ipsilateral recurrent stroke at an average interval of 43 months (range, 1-89 months), and five were left with permanent deficits. Definitive treatment included carotid endarterectomy in 27 of 50 (56%) or carotid stenting in 23 of 50 (46%). Two strokes were irrecoverable, and intervention was deferred. Web-associated thrombus was observed in 20 of 50 (40%) on angiography or grossly upon carotid exploration. Average interval from initial stroke to intervention was 39 days. After an average follow-up of 38 months, there was no reported postintervention stroke or mortality.

CONCLUSIONS

To our knowledge, this is the largest single-institution analysis of symptomatic CaWeb yet reported. Our series demonstrates that carotid duplex is inadequate for diagnosis, and that medical management is unacceptable for symptomatic CaWeb. Recurrent stroke occurred in all patients managed early in our experience with medical therapy alone. We have since adopted an aggressive interventional approach in cases of symptomatic CaWeb, with no postoperative stroke reported over an average follow-up of 38 months. In younger patients presenting with cryptogenic stroke, especially African American women, detailed review of lateral cerebral angiography or multi-planar, fine-cut CTA images is required to accurately rule out or diagnose CaWeb and avoid recurrent neurologic events.

Recurrent stroke shortly after mechanical thrombectomy secondary to carotid web: A case report

RATIONALE

Carotid web, a known source of thrombus for embolic stroke, presents a considerable risk of stroke recurrence. While case reports have demonstrated the safety and effectiveness of mechanical thrombectomy in treating carotid web-related stroke, the need for concurrent carotid artery stenting to prevent recurrent stroke immediately after thrombectomy remains unclear. This study aims to underscore the importance of immediate carotid artery stenting in preventing recurrent stroke following mechanical thrombectomy in patients with carotid web-related stroke.

PATIENT CONCERNS

A 43-year-old woman with acute onset of left limb weakness and slurred speech within 3 hours was admitted to the emergency department.

DIAGNOSES

Computed tomographic angiography confirmed the M1 segment occlusion of the right middle cerebral artery.

INTERVENTIONS

The patient received intravenous thrombolysis in the local hospital and mechanical thrombectomy in our stroke center.

OUTCOMES

Three days post-mechanical thrombectomy, there was a sudden exacerbation of her neurological deficit symptoms. A reexamination via computed tomographic angiography revealed a re-occlusion in M1 segment of the right middle cerebral artery, despite the implementation of stringent anticoagulation therapy for carotid web-related stroke.

LESSONS

Stroke patients with carotid web had a high risk of stroke recurrence and it was necessary to conduct carotid artery stenting to prevent stroke recurrence secondary to the carotid web immediately after mechanical thrombectomy.

[A case of recurrent stroke with carotid-web despite dabigatran treatment successfully treated by carotid endarterectomy]

We present a case of a 41-year-old female presenting with recurrence of ischemic stroke on subtherapeutic doses of dabigatran. She had a history of embolic stroke of undetermined sources at the age of 40, and underwent implantable cardiac monitor implantation and had started dabigatran. One year after the first ischemic stroke, she presented with sudden dysarthria and left hemiparesis and was admitted to our hospital. An MRI of the head revealed acute cerebral infarction in the right corona radiata, and an MR angiography revealed right M2 occlusion. Cervical 3D-CTA revealed a protruding structure on the posterior wall of the carotid artery bulb, which was diagnosed as carotid web. She underwent carotid endarterectomy, and the specimen was pathologically confirmed to be vascular malformation due to fibromuscular dysplasia.

Cerebrovascular Fibromuscular Dysplasia - A Practical Review

Fibromuscular dysplasia (FMD) is a rare idiopathic, segmental, noninflammatory and nonatherosclerotic arteriopathy of medium-sized arteries. It is classically considered to be a disease of young and middle adulthood, with females more commonly affected than males. FMD is a systemic disease. Although historically considered to be rare, cerebrovascular FMD (C-FMD) has now been recognized to be as common as the renovascular counterpart. Extracranial carotid and vertebral arteries are the most commonly involved vascular territories in C-FMD with the clinical presentation determined by vessels affected. Common symptoms include headaches and pulsatile tinnitus, with transient ischemic attacks, ischemic stroke and subarachnoid or intracerebral hemorrhage constituting the more severe clinical manifestations. Cervical artery dissection involving carotids more often than vertebral arteries and intracranial aneurysms account for the cerebrovascular pathologies detected in C-FMD. Our understanding regarding C-FMD has been augmented in the recent past on account of dedicated C-FMD data from North American, European and other international FMD cohorts. In this review article, we provide an updated and comprehensive overview on epidemiology, clinical presentation, etiology, diagnosis and management of C-FMD.

MR Angiography of Extracranial Carotid Disease

Magnetic resonance angiography sequences, such as time-of-flight and contrast-enhanced angiography, provide clear depiction of vessel lumen, traditionally used to evaluate carotid pathologic conditions such as stenosis, dissection, and occlusion; however, atherosclerotic plaques with a similar degree of stenosis may vary tremendously from a histopathological standpoint. MR vessel wall imaging is a promising noninvasive method to evaluate the content of the vessel wall at high spatial resolution. This is particularly interesting in the case of atherosclerosis as vessel wall imaging can identify higher risk, vulnerable plaques as well as has potential applications in the evaluation of other carotid pathologic conditions.

The carotid web: Current research status and imaging features

The carotid web is commonly found in the carotid bulb or the beginning of the internal carotid artery. It presents as a thin layer of proliferative intimal tissue originating from the arterial wall and extending into the vessel lumen. A large body of research has proven that the carotid web is a risk factor for ischemic stroke. This review summarizes the current research status of the carotid web and focuses on its imaging presentation.