Stroke Recurrence in First-Ever Symptomatic Carotid Web: A Cohort Study

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.

Subjects with carotid webs demonstrate pro-thrombotic hemodynamics compared to subjects with carotid atherosclerosis

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.

The differences between carotid web and carotid web with plaque: based on multimodal ultrasonic and clinical characteristics

OBJECTIVE

This study aimed to examine the clinical and multimodal ultrasonic characteristics differences between carotid web (CW) and CW with plaque as well as the potential risk factors for stroke caused by CW.

METHODS

We retrospectively enrolled patients diagnosed with CW by CTA or high-resolution MRI (HRMRI) and simultaneously underwent contrast enhanced ultrasound (CEUS) and superb microvascular imaging examinations from January 2015 to October 2022. The CW angle was measured using computer-aided software. The variations between CW and CW with plaque were evaluated, and univariable and multivariable logistic regressions were utilized to identify possible risk predictors for stroke caused by CW.

RESULTS

Two hundred ninety-nine patients with an average age of 60.85 (± 8.77) years were included. Sex, age, history of smoking, alcohol, hypertension, diabetes mellitus, homocysteine level, and treatment, as well as web length and thickness, luminal stenosis, location wall, number, CW angle, and CEUS enhancement, were quite different among CW and CW with plaque patients (p < 0.05). The logistic regression analysis showed that web length was an independent predictor of luminal stenosis in CW patients. For patients with CW and plaque, plaque and web thickness, as well as plaque enhancement, were associated with stenosis. Furthermore, luminal stenosis and plaque length were risk factors for symptoms.

CONCLUSION

The multimodal ultrasonic and clinical manifestations of CW and CW with plaque are quite different. Web length is an independent risk factor for carotid artery stenosis in CW patients, whereas luminal stenosis and plaque length were risk factors for symptoms in CW with plaque patients.

CRITICAL RELEVANCE STATEMENT

Exploring the similarities and differences between the carotid web and the carotid web with plaque, based on the stereo-geometric spatial position relationship and hemodynamic changes, may provide further insights into the underlying mechanisms of stroke occurrence caused by the carotid web.

KEY POINTS

1. Multimodal ultrasonic and clinical manifestations of carotid web and carotid web with plaque are substantially different. 2. A thin triangular endoluminal defect is identified as a typical feature of the web on superb microvascular imaging, and two kinds of typical ultrasonic features of CW with plaque are also identified. 3. Web length is an independent risk factor for carotid stenosis in carotid web patients, whereas luminal stenosis and plaque length are risk factors for symptoms in patients with CW and plaque.

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.

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.

Carotid Web as a Source of Thromboembolism in a Young African American Female

Background: Carotid webs are nonatherosclerotic fibrous bands that may alter hemodynamic flow and increase the risk of platelet aggregation, leading to thromboembolism in young, otherwise healthy individuals. Although rare, carotid webs are important causes of thromboembolic strokes and are often overlooked in the routine workup for a stroke. Treating physicians and radiologists must recognize and properly manage patients who present with carotid webs to prevent recurrent thromboembolism. Case Report: A healthy 30-year-old female presented with slurred speech and unilateral left upper and lower extremity numbness. Imaging modalities showed an acute infarction of the right middle cerebral artery and bilateral carotid webs. The patient was managed operatively with a right carotid endarterectomy and discharged on day 3 of admission on a regimen of ticagrelor, amlodipine, and aspirin. The patient was asymptomatic at 1-year follow-up. Conclusion: Our case highlights the clinical relevance of considering carotid web as a potential etiology for ischemic stroke in young, otherwise healthy patients and emphasizes the importance of timely diagnosis and appropriate management to prevent recurrent cerebrovascular events.

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.

Advances in Management of the Stroke Etiology One-Percenters

PURPOSE OF REVIEW

Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care.

RECENT FINDINGS

Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.

Dual-layer carotid stenting for symptomatic carotid web: Results from the Caroweb study

BACKGROUND & PURPOSE

Carotid Web (CaW) is a growingly recognized cause of ischemic stroke, associated with a high recurrence risk. Several therapeutic strategies have been proposed as a tertiary prevention including carotid stenting, endarterectomy and antithrombotic medications. Among these, carotid stenting with dual-layer stent may be promising to adequately cover the focal arterial dysplasia. Our aim was to investigate the safety and efficacy of the Casper stent in the treatment of symptomatic CaW.

METHODS

We conducted a retrospective analysis of consecutive patients presenting with a symptomatic CaW and included in the ongoing prospective observational multicenter CAROWEB registry. The study period was January 2015 to December 2021. Inclusion criteria were CaW treated with dual-layer Casper stent. Patients treated with other types of carotid stent, endarterectomy or antithrombotic medication were excluded. Clinical and radiological initial data and outcomes were recorded.

RESULTS

twenty-seven patients (with 28 caw) were included. median age was 52 (iqr: 46-68). median delay between index cerebrovascular event and cervical stenting was 9 days (IQR: 6-101). In all cases, the cervical carotid stenting was successfully performed. No major perioperative complication was recorded. No recurrent stroke or transient ischemic attack was observed during a median follow-up time of 272 days (IQR: 114-635). Long-term imaging follow-up was available in 25/28 (89.3%) stented CaW with a median imaging follow-up of 183 days (IQR: 107-676; range: 90-1542). No in-stent occlusion or stenosis was detected.

CONCLUSION

In this study, carotid stenting with dual-layer Casper stent in the treatment of symptomatic CaW was effective regarding stroke recurrence prevention and safe, without procedural nor delayed detected adverse event. However, the optimal therapeutic approach of symptomatic CaW still needs to be explored through randomized trials.

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

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.

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.

Multimodality imaging of carotid web: A case report and literature review

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.