Clinical, imaging, and management features of symptomatic carotid web: Insight from CAROWEB registry

BACKGROUND

Although carotid web (CaW) is increasingly diagnosed as a cause of cryptogenic stroke, data are still limited to monocentric small sample cohort. To broaden knowledge on symptomatic CaW, CAROWEB registry has been recently implemented.

AIMS

In a large cohort of symptomatic CaW patients, we described epidemiologic characteristics, admission clinical and imaging features, and the current management including the secondary preventive strategy choice made in comprehensive French Stroke Units.

METHODS

CAROWEB is an ongoing French observational multicenter registry enrolling consecutive CaW patients diagnosed after an ipsilateral ischemic stroke (IS) or transient ischemic attack (TIA). Submitted cases were validated by two experienced neurologist and neuroradiologist. Clinical, imaging, and management features were collected for this study.

RESULTS

Between June 2019 and December 2021, 244 cases were submitted by 14 centers, 42 rejected, and 202 included (IS, 91.6%; TIA, 7.9%; retinal infarction, 0.5%; mean age, 50.8 ± 12.2 years; female, 62.9%; Caucasian, 47.5%; Afro-Caribbean, 20.3%). IS patients showed median (interquartile range (IQR)) admission National Institutes of Health Stroke Scale (NIHSS) score, 8 (2-15); intracranial artery occlusion, 71.8%; ipsilateral chronic cerebral infarction (CCI), 16.3%; and reperfusion treatment, 57.3%. CaW was not identified during the mechanical thrombectomy procedure in 30 of 85 (35.3%) patients. Secondary prevention was invasive in 55.6% (stenting, n = 80; surgery, n = 30). In multivariable analysis, the invasive therapeutic option was associated with ipsilateral CCI (odds ratio (OR): 4.24 (1.27-14.2), p = 0.019) and inversely associated with risk factors (OR: 0.47 (0.24-0.91), p = 0.025) and admission NIHSS score (OR: 0.93 (0.89-0.97), p = 0.001).

CONCLUSION

CaW must be considered in all ethnic groups including Caucasians. Secondary prevention is heterogeneous in large French Stroke Centers. The absence of risk factors, milder severity strokes, and ipsilateral CCI were predictive variables of secondary invasive treatment. The high rate of invasive treatment suggests that medical treatment alone is deemed ineffective to avoid recurrence and emphasize the need of randomized trials.

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.

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.

Recurrent stroke in young adults caused by atypical fibromuscular carotid dysplasia

Background

Carotid Web and focal carotid diaphragm are atypical fibromuscular dysplasia. The bilateral stroke due to this dysplasia is extremely rare. We will report a series of three young patients, admitted for a bilateral ischemic stroke caused by carotid bulb web and internal carotid diaphragm. Also, we will discuss their manifestations and treatment modalities.

Case presentations

In our study, we will report a series of three North African patients, two females an one male, at the mean age of 37, admitted for an ischemic stroke caused by bilateral carotid bulb web and bilateral internal carotid diaphragm.All of our patients were young and didn't have a history of drug use.

Conclusions

In our series, only end-vascular treatment was performed which was necessary to prevent any recurrence. Antiplatelet therapy was used in all cases to prevent any stroke during the follow-up.

The carotid diaphragm, an often overlooked cause of stroke by cardiologists

Carotid diaphragm is a rare cause of stroke. Because of its rarity, it remains often undiagnosed. We report the case of four patients who presented a stroke due to carotid diaphragm. The diagnosis was made either by ultrasound Doppler, computed tomography-angiography or angiography. Two of the four patients were managed by carotid stenting and the other two by surgery. The follow-up was normal. Carotid diaphragm stroke is associated with a high risk of recurrence if not well managed. Therefore, the knowledge of this rare entity is necessary.

The Value of Contrast-Enhanced Ultrasound in the Evaluation of Carotid Web

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.

Delayed Thrombus on Carotid Web: Case Report With Escalation of Treatment

Carotid artery web is an underrecognized source and is found in about 1-2% of patients with acute ischemic stroke. Although, first described four decades ago, optimal therapy for carotid web is not yet known. Carotid stenting and endarterectomy are increasingly used for carotid web treatment, given its definitive treatment and avoiding the complications associated with anticoagulation. The case reported here is of an ischemic stroke secondary to a mobile thrombus on a carotid web evident on CT angiography and successful definitive treatment with delayed carotid wall stent placement. In young patients who have a diagnosis of ischemic stroke, the carotid web should be on the differential and adequate neuroimaging with either CTA or DSA should be pursued.

Ultrasonic characteristics of carotid webs

PURPOSE

This study aimed to retrospectively analyze the ultrasonographic images of 46 cases of carotid web (CW) and summarize their manifestations to reduce the rate of misdiagnosis.

METHODS

For the analysis of ultrasonic manifestations, 46 patients with a confirmed diagnosis of CW by digital subtraction angiography (DSA) and CT angiography (CTA) in our hospital from January 2015 to October 2020 were collected. The location and the morphology of CW, the presence of a plaque at the base and thrombus at the surrounding of the CW, and whether they resulted in arteriostenosis were discussed.

RESULTS

The average age of 46 patients was 43.23 ± 4.89 years old and there were 18 males and 28 females. Fifteen patients were admitted with cerebral infarction. The CW was located at the initial segment of the internal carotid artery in 22 cases, the bifurcation of the carotid artery in 20 cases, and the common carotid artery in 4 cases. CW in 5 patients was longer than half of the artery diameter, two patients with "cliff-like" arteriostenosis, 29 patients with plaques, and 16 patients with thrombi. The CW grew in the direction of the blood flow without obvious fluttering. The CW has a higher display rate on the ultrasound longitudinal section than the transverse section.

CONCLUSION

We identified some typical ultrasound characteristics of CW. Recognizing them will improve diagnostic accuracy of CW by ultrasonography.

Common Carotid Artery Diaphragm presenting as transient syncope

Carotid diaphragm usually can cause artery stenosis essentially affecting the internal carotid artery (ICA) beyond the bulb segment.  Patients are often middle aged and the onset of symptoms typically begins with syncopes leading to ischemic stroke.  More than 50 cases have been reported in which all lesions showed as stenosis located in the ICA, in this article, we report a rare common carotid artery (CCA) diaphragm revealed in a 59 year-old female suffering from transient syncopes. This is the third case reported in the literature.

Diagnostic Yield of Neck CT Angiography in Young Adults With Anterior Circulation Ischemic Stroke: A Community Based Study

Background and Purpose

Few community-based studies investigating young adult strokes exist. The aim of this study was to determine the diagnostic yield of head and neck CTA in evaluation of anterior circulation ischemic stroke in young adults.

Materials and Methods

This retrospective review is limited to patients between the ages of 18-50 presenting to the Mayo Clinic Rochester emergency department or referred from smaller institutions in adjacent counties. Patients with posterior circulation infarcts, amaurosis fugax, central retinal artery occlusion or transient ischemic attacks were excluded. The presence of carotid dissection, webs, plaque, or other high-risk lesions were recorded.

Results

A total of 136 patients met inclusion criteria. Mean degree of carotid stenosis ipsilateral to infarct was 14.1%, compared to 6.5% on the contralateral side (p = .006). Ipsilateral mean carotid wall thickness measured .79 mm, compared to contralateral thickness of .80 mm (p = .51). Ipsilateral low-density plaque was observed in 22 patients (16.2%), and 21 patients (15.4%) on the contralateral side (p = .87). Ipsilateral calcified plaque was observed in 37 patients (27.2%), and 29 patients (21.3%) on the contralateral side (p = .31). 20 (14.7%) ipsilateral dissections were noted, compared to 4 (2.9%) contralateral dissections (p = .001). 3 (2.2%) ipsilateral carotid webs were identified, compared to 0 contralateral webs (p = .25).

Conclusion

Carotid dissection was the most common cause of anterior circulation infarct identified on cervical CTA in this population. Carotid webs and atherosclerosis were not common findings.

Current progress in clinical, molecular, and genetic aspects of adult fibromuscular dysplasia

Fibromuscular dysplasia (FMD) is a non-atherosclerotic vascular disease that may involve medium-sized muscular arteries throughout the body. The majority of FMD patients are women. Although a variety of genetic, mechanical, and hormonal factors play a role in the pathogenesis of FMD, overall, its cause remains poorly understood. It is probable that the pathogenesis of FMD is linked to a combination of genetic and environmental factors. Extensive studies have correlated the arterial lesions of FMD to histopathological findings of arterial fibrosis, cellular hyperplasia, and distortion of the abnormal architecture of the arterial wall. More recently, the vascular phenotype of lesions associated with FMD has been expanded to include arterial aneurysms, dissections, and tortuosity. However, in the absence of a string of beads or focal stenosis, these lesions do not suffice to establish the diagnosis. While FMD most commonly involves renal and cerebrovascular arteries, involvement of most arteries throughout the body has been reported. Increasing evidence highlights that FMD is a systemic arterial disease and that subclinical alterations can be found in non-affected arterial segments. Recent significant progress in FMD-related research which has led to improved understandings of the disease's clinical manifestations, natural history, epidemiology, and genetics. Ongoing work continues to focus on FMD genetics and proteomics, physiological effects of FMD on cardiovascular structure and function, and novel imaging modalities and blood-based biomarkers that can be used to identify subclinical FMD. It is also hoped that the next decade will bring the development of multi-centred and potentially international clinical trials to provide comparative effectiveness data to inform the optimal management of patients with FMD.

Prevalence and site of predilection of carotid webs focusing on symptomatic and asymptomatic Japanese patients

OBJECTIVE

Carotid webs (CWs) have increasingly been recognized as a cause of recurrent ischemic stroke. However, the natural history and clinical course of CWs remain unclear. The authors aimed to clarify the prevalence, imaging features, and optimal treatment of CWs in a Japanese cohort study.

METHODS

A series of 444 consecutive Japanese patients who had undergone CTA of the head and neck between April 2011 and October 2016 was retrospectively reviewed. CW was diagnosed on CT angiograms as a membrane-like intraluminal filling defect along the posterior wall of the carotid bulb or the origin of the internal carotid artery (ICA) on oblique sagittal images and a corresponding thin septum on axial images.

RESULTS

Two patients with CWs were identified among 132 patients with suspected stroke. The prevalence of CWs among symptomatic patients with suspected stroke was 1.5%. The prevalence of asymptomatic CWs was 2.2% (7 of 312 cases). The CWs were located in the posterior wall of the carotid bulb in 7 patients and just distal to the ICA origin in 2 patients. There were no apparent differences in the location or lesion length between symptomatic and asymptomatic CWs. Four of the 7 asymptomatic CWs remained asymptomatic for at least 2 years of follow-up. Two patients with symptomatic CWs developed recurrent cerebral infarction and transient ischemic attack despite being on a regimen of oral antiplatelet agents, and carotid endarterectomy was performed as radical treatment. Patients with CWs were younger than controls (median age 55 vs 69 years, p = 0.003) and were less frequently male than controls (33% vs 72%, p = 0.025). CW cases showed significantly fewer common atherosclerosis risk factors than the control group (p < 0.05).

CONCLUSIONS

Although limited to CTA patients, this study reported on the prevalence and common site of CWs, focusing on symptomatic and asymptomatic Japanese patients. Extensive cross-sectional and prospective observational studies are warranted to elucidate the overall prevalence and natural history of CWs.

Carotid webs associated with ischemic stroke. Updated general review and research directions

Carotid web (CaW) is an intimal variant of fibromuscular dysplasia strongly associated with ipsilateral cerebral infarction. Although considered rare, it is a recent and increasing concern for physicians involved in stroke diagnosis and management. The present general review relies on a systematic literature analysis and aims to update readers on the latest knowledge in the field of symptomatic CaW (syCaW). CaW associated with ipsilateral cerebral infarction or transient ischemic attack has been identified in 189 patients. Ischemic strokes (IS) mostly occur in middle age (mean 46 years) and predominately in females (66%). The high frequency of African descendant patients among case reports and series (58%) suggests an ethnic susceptibility for CaW development. CaW features are characterised by a shelf-like intraluminal defect on contrast sagittal imaging, a linear defect that splits the lumen on axial section, a post-contrast stagnation rostral to the lesion and a frequent contralateral mirrored CaW (26.6%). An artery-to-artery embolism mechanism is widely accepted via CaW blood stasis, thrombus formation and clot fragmentation scattered by blood flow. Therefore, cerebral infarctions are often large related to a high proportion of proximal occlusion (62.5%). CaW confers a high rate of IS recurrence despite standard anti-platelet treatment that reaches 33.3% of patients prospectively followed with a median time to event of one year. Although no randomised therapeutic studies are available, surgery (n=39) or stenting (n=50) have been often proposed and seem to avoid recurrences. CaW clearly emerges as a cause of cryptogenic embolic stroke and should be systematically investigated in routine. A large number of points remain to be elucidated and CaW patients should be steadily included in registries and randomised therapeutic studies.

[Fibromuscular dysplasia and its neurological manifestations]

The authors present the current data on the classification, epidemiology, etiology, neurological manifestations, prognosis, diagnosis, and treatment of patients with fibromuscular dysplasia (FMD). The review is based on the selection of publications by searching PubMed for keywords from the first sources until March 2019. FMD is a segmental non-atherosclerotic and non-inflammatory disease of large- and medium-caliber arteries leading to their stenosis. The disease occurs mostly in women (90%), and manifests itself in the 5th decade of life. In the cerebrovascular form of FMD, the extracranial internal carotid artery and the vertebral artery are usually affected. Diagnosis is based on the identification of alternation of narrowing and dilation of arteries using angiography (the string of beads sign (multifocal form)). Neurological manifestations include headache, tinnitus, and ischemic stroke, usually due to the dissection or stenosis, rarely, intracerebral or subarachnoid hemorrhages. The prognosis in most cases is favorable, relapses of strokes are rare. Treatment includes antiplatelet agents, if they are ineffective to prevent recurrence of ischemic stroke, endovascular treatment is carried out. Approaches to the treatment of intracranial aneurysms do not differ from those in patients without FMD.

Safety and feasibility of carotid revascularization in patients with cerebral embolic strokes associated with carotid webs and histopathology revisited

INTRODUCTION

Carotid web is increasingly recognized as the cause of ischemic embolic strokes in younger patients. The best way to treat carotid web is debatable and carotid artery stenting (CAS) has been reported as a treatment for the carotid web in only a few case series. In this study we evaluate the safety and feasibility of CAS in symptomatic carotid webs and examined the histopathology of a carotid web.

MATERIALS AND METHODS

At our institution between 2017 and 2019, 10 consecutive patients with symptomatic carotid webs were treated. We retrospectively analyzed the data for patient demographics, clinical presentation, imaging, treatment methodology and follow up.

RESULTS

All the patients had presented with ipsilateral embolic stroke. The mean age at presentation was 50 years (range 37-71) with seven female and three male patients. All patients underwent CAS except one patient who underwent carotid endarterectomy (CEA). In one stented patient, there was significant hypotension in the post-procedural period lasting a week. The patients were followed for a mean of 5.5 months (range one day-12 months). No recurrent stroke or transient ischemic attack (TIA) occurred. Surgical pathological studies confirmed fibromuscular dysplasia in one specimen.

CONCLUSION

In our experience CAS for carotid web is feasible and safe in patients presenting with ischemic embolic strokes.

Surgical Treatment of Carotid Webs in Symptomatic Young Adults

BACKGROUND

Carotid webs are possibly responsible for ischemic stroke in young adults. We aim to report a case series study about surgical treatment of this uncommon condition.

METHODS

We performed a retrospective analysis on clinical, imaging, pathological, operative data, and outcomes about consecutive patients affected with carotid ischemic stroke due to carotid webs in a single institution.

RESULTS

During a three-year period, a total of 123 patients were treated for carotid stroke, in five cases (4%) (median age 48.4 years, range 44-53, 2 men and 3 women, median NIHSS score 8.4, range 4-17) due to a carotid web. Patients were all Caucasian excepting for one. No severe comorbidities were detected. Preoperatively thrombectomy of middle cerebral artery was needed in three cases. Surgical treatment consisted in web resection and carotid end-to-end anastomosis (3 cases) or web excision and patch angioplasty (2 cases). In-hospital NIHSS score improved postoperatively of more than 2 points (median 3.6, range 2-7) in all cases. No major complications were detected. One patient experienced a local hematoma treated conservatively. At a mean follow-up of 18 months (range 1-35 months), no recurrent stroke nor myocardial infarction nor death were remarked.

CONCLUSIONS

In young patients presenting with ischemic stroke without neither conventional stroke risk factors nor other possible sources of embolism, a carotid web should be suspected. Surgery guarantees excellent results in prevention of recurrences.

Carotid web leads to new thrombus formation: computational fluid dynamic analysis coupled with histological evidence

Carotid web has been recognized as a rare cause of ischemic stroke with high recurrence rate. We describe a 48-year-old woman with carotid web who developed embolic stroke. We obtained a fresh thrombus from the internal carotid artery when carotid endarterectomy was performed. A preoperative computational fluid dynamics (CFD) study showed stagnation of blood around the web structure as well as the low wall shear stress. The rheological analysis newly disclosed mechanisms of thrombus formation related to the carotid web. CFD study in the carotid web may determine indication and timing of surgical interventions with further accumulation of clinical evidence.

Carotid webs management in symptomatic patients

BACKGROUND

Atypical fibromuscular dysplasia (AFMD), also known as carotid web, is a rare underdiagnosed shelf-like fibrous tissue arising from the posterior carotid artery bulb that is a cause of cryptogenic stroke of the anterior cerebral vascularization. Despite the recurrence and severity of strokes caused by embolization associated with AFMD, there are no recommendations on the best strategy to manage single and bilateral lesions, which have unsatisfactory outcomes when treated with medical treatment exclusively.

METHODS

From January 2016 to April 2019, 365 patients were operated on for a carotid stenosis in our institution. This cohort included 11 patients (3%), with a median age of 41 years (range, 39-51 years), referred by a stroke unit, treated for a symptomatic (10 strokes and 1 recurrent transient ischemic attack) AFMD lesion. Preoperative workup revealed a contralateral similar lesion in 45% of patients (5/11), which all also underwent surgery during a subsequent hospitalization. The diagnosis was confirmed by histologic examination when open surgery was performed. The 30-day and 1-year outcomes were retrospectively reviewed.

RESULTS

Of the 16 AFMD lesions operated, 13 were treated by open surgery (2 by classic endarterectomy and 11 by internal carotid resection-anastomosis) and 3 by carotid artery stenting, respectively, with a mean delay of 85.5 days and 20.5 days after the latest stroke. There was one complication after stenting (external iliac rupture) that was treated by a covered stent, and no perioperative complications after open surgery. The follow-ups at 30 days and 1 year were uneventful for all patients, without any deaths or stroke recurrences.

CONCLUSIONS

Symptomatic AFMD is a rare cause of cryptogenic stroke. Bilateral lesions are frequent. Early intervention is associated with favorable perioperative and 1-year outcomes. Open surgery is the first-line therapeutic option in this young patient population.

Carotid Web Misdiagnosis

BACKGROUND

A carotid web (CW), an atypical fibromuscular dysplasia, is rare and may cause ischemic stroke. It is challenging to recognize a CW promptly and treat it accordingly. We report a case of an initially misdiagnosed CW.

CASE DESCRIPTION

A 48-year-old man with recurrent cerebral infarction was transferred to our hospital for bypass surgery. Imaging performed at our facility showed multiple old infarct lesions and cerebral tissue hypoperfusion in the occluded left middle cerebral artery territory. Bypass surgery was performed without perioperative complications. While searching for the cause of his stroke, we found a thin intraluminal filling defect along the posterior wall of the left carotid bulb just beyond the carotid bifurcation on sagittal maximal intensity projection images, axial thin-cut images, and volume rendering images. The defect was diagnosed as a CW. It was also detected on follow-up ultrasonography. Owing to our initial unawareness, we did not photograph the carotid bulb during preoperative digital subtraction angiography and postoperative computed tomography angiography. Although the patient was treated with bypass, the persistence of the factors underlying the CW may induce further thrombosis and subsequent occlusion of his ipsilateral anterior cerebral artery.

CONCLUSIONS

Clinicians should be aware of CW as a potential cause of ischemic stroke. Head and neck computed tomography angiography is a reliable imaging method to detect CWs.

First international consensus on the diagnosis and management of fibromuscular dysplasia

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD) which was commissioned by the Working Group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

Fibromuscular Dysplasia and Its Neurologic Manifestations: A Systematic Review

Importance

Data on neurologic manifestations of fibromuscular dysplasia (FMD) are rare, and current knowledge remains limited.

Objectives

To present a comprehensive review of the epidemiologic characteristics, management, and prognosis of the neurologic manifestations associated with cerebrovascular FMD (ie, involving cervical or intracranial arteries) and to guide future research priorities.

Evidence Review

References were identified through searches of PubMed from inception to December 2017 using both the medical subject headings and text words. Additional sources were also identified by reviewing reference lists of relevant articles and through searches of the authors' personal files. Selected articles described at least 1 clinical or radiologic feature and/or outcome of cerebrovascular FMD. Isolated case reports could be included if they described interesting or noteworthy manifestations of FMD.

Findings

A total of 84 relevant references were identified. Diagnosis of cerebrovascular FMD is based on the appearance of alternating arterial dilatation and constriction ("string of beads") or of focal narrowing, with no sign of atherosclerotic or inflammatory lesions. Although the diagnosis is easily apparent on results of radiographic imaging, making a diagnosis can be challenging in children or individuals with atypical phenotypes, such as purely intracranial FMD and arterial diaphragm. Involvement of multiple arteries is common, and there is increased incidence of cervical artery dissection and intracranial aneurysms. A variant in the PHACTR1 gene has been associated with FMD as well as cervical artery dissection and migraine, although less than 5% of cases of FMD are familial. Headaches, mainly of the migraine type, are observed in up to 70% of patients with FMD. Cerebrovascular FMD is mostly asymptomatic, but the most frequent neurologic manifestations include transient ischemic attack and ischemic stroke, notably in the presence of associated cervical artery dissection. Other conditions associated with FMD include subarachnoid hemorrhage and, rarely, intracranial hemorrhage. Management relies on observational data and expert opinion. Antiplatelet therapy is considered reasonable to prevent thromboembolic complications. Endovascular therapy is typically restricted to cases with symptomatic stenosis despite optimal medical therapy or in those with rupture of an intracranial aneurysm.

Conclusions and Relevance

Longitudinal cohort studies of individuals of multiple ethnicities with biosampling are needed to better understand the risk factors, pathophysiological features, and outcomes of FMD. Patient advocacy groups could assist researchers in answering patient-centered questions regarding FMD.

Stent Placement for Disabling Pulsatile Tinnitus Caused by a Lateral Sinus Stenosis: A Retrospective Study

BACKGROUND

Lateral sinus stenosis is a little-known cause for pulsatile tinnitus (PT). In several small series, stenting has been described as an effective treatment for disabling PT linked with this type of stenosis.

OBJECTIVES

To describe the clinical, radiological, and manometric characteristics of patients treated for disabling PT by lateral sinus stenosis. Assessment of the efficacy of stenting for this indication.

METHODS

Retrospective study of patients treated for isolated PT by stenting of a lateral sinus stenosis in our institution, between 2009 and 2015.

RESULTS

Fourteen patients were included in our study. All of them were women. The median age at the onset of symptoms was 39.0 (21.0) years. The median body mass index was 28.5 (7.0) kg/m 2 . Stenting of the lateral sinus led to the disappearance of PT without recurrence in 13 patients. In one patient, stenting did not modify the noise. In this case, another cause of PT was diagnosed after stent placement.

CONCLUSION

Lateral sinus stenosis is a curable cause of venous PT. Other causes of PT must be ruled out before an endovascular treatment is undertaken, due to the frequent asymptomatic nature of Pacchioni granulations in the lateral sinus. Treatment by stenting is effective in all cases, provided that stenosis underlies the PT.

Transient Ischemic Attack and Carotid Web

BACKGROUND AND PURPOSE

Carotid web was recognized as a cause of ischemic stroke. We sought to determine the clinical and imaging profiles of patients with a carotid web as well as its association with TIA.

MATERIALS AND METHODS

A retrospective review of carotid CT angiography studies and brain MR imaging in patients with TIA during the past 3 years (n = 135) was performed to determine the presence of carotid webs by 2 experienced neuroradiologists according to previously published criteria. Demographics and clinical and imaging characteristics are shown by descriptive statistics for patients with an identified carotid web. The agreement in the detection of carotid webs between 2 neuroradiologists was examined using κ statistics.

RESULTS

There were 12 (8.9%) carotid webs at the symptomatic bifurcation and 1 carotid web (0.7%) at the asymptomatic bifurcation, and no hyperintensity was seen on DWI of these 12 patients. Eight of these 12 (75%) patients with a carotid web were women. None of the 12 patients with a carotid web had major risk factors or other causes of TIA. Fair-to-good interobserver agreement (κ = 0.87) was seen for diagnosing a carotid web with CT angiography. The rate (10/12, 83.3%) of short-term recurrent episodes of TIA in patients with TIA with a carotid web was significantly higher than that of patients without a carotid web (15/123, 12.2%) (P < .001).

CONCLUSIONS

The incidence of carotid web in patients with TIA was 8.9%. There is an association between carotid web and patients with TIA without other identified risks. Carotid web may be an underestimated risk factor for TIA.

First International Consensus on the diagnosis and management of fibromuscular dysplasia

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD), which was commissioned by the working group ‘Hypertension and the Kidney’ of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

Consensus statement on current and emerging methods for the diagnosis and evaluation of cerebrovascular disease

Cerebrovascular disease (CVD) remains a leading cause of death and the leading cause of adult disability in most developed countries. This work summarizes state-of-the-art, and possible future, diagnostic and evaluation approaches in multiple stages of CVD, including (i) visualization of sub-clinical disease processes, (ii) acute stroke theranostics, and (iii) characterization of post-stroke recovery mechanisms. Underlying pathophysiology as it relates to large vessel steno-occlusive disease and the impact of this macrovascular disease on tissue-level viability, hemodynamics (cerebral blood flow, cerebral blood volume, and mean transit time), and metabolism (cerebral metabolic rate of oxygen consumption and pH) are also discussed in the context of emerging neuroimaging protocols with sensitivity to these factors. The overall purpose is to highlight advancements in stroke care and diagnostics and to provide a general overview of emerging research topics that have potential for reducing morbidity in multiple areas of CVD.

Multicenter Experience with Stenting for Symptomatic Carotid Web

Background

A carotid web (CaW) is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. CaW has been associated with recurrent strokes and conventionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic CaWs.

Methods

Retrospective review of consecutive patients admitted to 5 comprehensive stroke centers who were identified to have a symptomatic CaW and treated with carotid stenting. A symptomatic CaW was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT angiography (CTA) and confirmed with conventional angiography in patients with negative stroke workup.

Results

Twenty-four patients with stented symptomatic CaW were identified (stroke in 83% and transient ischemic attack in 17%). Their median age was 47 years (IQR 41-61), 14 (58%) were female, and were 17 (71%) black. The degree of stenosis by NASCET was 0% (range 0-11). All patients were placed on dual antiplatelets and stented at a median of 9 days (IQR 4-35) after the last event. Closed-cell stents were used in 18 (75%) of the cases. No periprocedural events occurred with the exception of 2 cases of asymptomatic hypotension/bradycardia. Clinical follow-up after stent placement occurred for a median of 12 months (IQR 3-19) with no new cerebrovascular events noted. Functional independence at 90 days was achieved in 22 (91%) patients. Follow-up vascular imaging (ultrasound n = 18/CTA n = 5) was performed at a median of 10 months (IQR 3-18) and revealed no stenosis.

Conclusions

Stenting for symptomatic CaW appears to be a safe and effective alternative to surgical resection. Further studies are warranted.

Carotid Stenting for Treatment of Symptomatic Carotid Webs: A Single-Center Case Series

Background and Purpose

Carotid webs are an increasingly recognized cause of acute is-chemic stroke, particularly in younger adults. The optimal medical and surgical strategies for managing these lesions have not been well established. We report a single-center case series of carotid stenting for treatment of symptomatic carotid webs.

Materials and Methods

Consecutive patients undergoing stent placement for treatment of symptomatic carotid webs were included. Carotid webs were defined as a thin intraluminal filling defect along the posterior wall of the carotid bulb just beyond the carotid bifurcation on CTA. Data were collected on demographic characteristics, antiplatelet management, clinical presentation, imaging findings, treatment characteristics, complications, and stroke recurrence rates. Descriptive statistics are reported.

Results

A total of 4 patients were treated. Their mean age was 44 years (range 30-50). Three patients were female and 1 was male. All patients were symptomatic presenting with ipsilateral transient ischemic attacks or stroke. Patients were placed on dual antiplatelet therapy with ticagrelor and aspirin prior to the procedure. There were no ischemic or hemorrhagic complications. Three patients had postoperative bradycardia, 1 of whom required atropine immediately following stenting. No patients had recurrent ischemic events.

Conclusions

Stent placement for treatment of carotid webs can be performed safely. Further studies are needed to confirm our findings.

Neurointerventional management of carotid webs associated with recurrent and acute cerebral ischemic syndromes

BACKGROUND

A carotid web can be defined as an endoluminal shelf-like projection often noted at the origin of the internal carotid artery (ICA) just beyond the bifurcation. Diagnosis of a carotid web as an underlying cause of recurrent ischemic stroke is infrequent and easily misdiagnosed as an atheromatous plaque. Surgery has traditionally been used to resect symptomatic lesions while there is no enough evidence supporting medical therapy as the sole management. To our knowledge there is only one report about carotid artery stenting (CAS) as a definite management of carotid web and no previous reports of acute large-vessel occlusions undergoing mechanical thrombectomy in the setting of carotid web as the etiology.

CASE REPORT

We report two cases: The first presented with recurrent ischemic stroke in the same arterial territory and the other with an emergent left middle cerebral artery (MCA) occlusion that underwent endovascular mechanical thrombectomy in which initial computed tomographic angiograms (CTA) suggested carotid web etiologies. Following confirmation with digital subtraction angiography (DSA), both patients ultimately underwent endovascular carotid stenting instead of surgical resection for definitive carotid web treatment.

CONCLUSIONS

Carotid webs are a rare cause of ischemic stroke in young and middle-aged adults that can readily be identified by CTA. Endovascular management may include emergent mechanical thrombectomy for large-vessel thromboembolic complications, and for definitive treatment with carotid stenting across the carotid web as an alternative to surgical resection and medical management for secondary stroke prevention.

Internal Carotid Artery Web: Doppler Ultrasound with CT Angiography correlation

We present a case of an internal carotid web, detected on duplex ultrasound and confirmed by CT angiography. To our knowledge, this is only the third reported ultrasound case in the imaging literature. This vascular abnormality can cause a clinically significant carotid stenosis and is a risk factor for recurrent embolic cerebrovascular events. Due to small size and poor awareness among radiologists, carotid webs are often under-diagnosed on non-invasive imaging modalities. Improved awareness including knowledge of salient imaging features is useful as early diagnosis leading to appropriate intervention can eliminate the risk of future cerebrovascular events.