Bilateral carotid web successfully treated with endarterectomy, a case report

The patient was a middle-aged male with the recurrent transient ischemic attack caused by carotid web, and the common symptoms include recurrent left limb weakness and numbness. According to the results of the CT angiography, the digital substraction angiography, the magnetic resonance angiography and the colour-Doppler ultrasound of the neck, the patient was considered with carotid artery web. After conventional medical treatment such as anti-platelet aggregation, lipid regulation and improvement of cerebral circulation, the patient′s symptoms did not improve significantly. Later, the patient underwent carotid endarterectomy. The pathological examination results of the tissue from the surgery confirmed the patient with carotid artery web. Moreover, after surgery, the patient did not experience transient ischemic attack any more. Key words: Carotid web; Cerebral ischemia attack; Carotid endarterectomy

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.

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

BackgroundTo the best of our knowledge, no previous studies on carotid webs with atherosclerosis plaque have been conducted. Thus, both radiologists and clinicians have insufficient knowledge of this disease, which could lead to misdiagnosis and missed diagnosis. An accurate diagnosis is beneficial to clinical management and prevention of stroke. Here, we present a case of a carotid web with an atherosclerotic plaque, which was confirmed by histopathology and was treated at the Department of Neurosurgery, Beijing Tiantan Hospital.Case presentationWe report a rare case of a carotid web with an atherosclerotic plaque in a 61-year-old Han man. He presented to our hospital with history of intermittent dizziness and slurred speech for 1.5 years and numbness of both upper limbs for 4 months. A computed tomography angiography examination indicated severe stenosis at the beginning of the left internal carotid artery with plaque surface ulceration. Doppler ultrasound examination showed a carotid web with a thin isoechoic plaque and a membrane-like structure protruding into the lumen from the lateral posterior wall at the beginning of the left internal carotid artery. The thin isoechoic plaque could be seen at the base of the membrane-like structure. Carotid endarterectomy was performed to alleviate symptoms. A carotid web with atherosclerosis was diagnosed intraoperatively, and postoperative pathology confirmed extensive intima fibroid hyperplasia accompanied with myxoid degeneration. The base of the carotid web was attached to the thin atherosclerosis plaque, and between the web and the plaque, a cavity was observed. In this case report, we aim to discuss the diagnosis of carotid web with atherosclerosis, its physiopathology and management, and the possible reasons for missed diagnosis or misdiagnosis.ConclusionCarotid webs with atherosclerosis have no known etiological factors and are rarely reported. Thus, carotid webs could be easily confused with ulcerations on the surface of the atherosclerosis plaque. The diagnosis could be difficult and effective management remains indeterminate. Moreover, prompt recognition of this disease is key to correct treatment and management. Hence, this case report and the relevant data in the literature could contribute to the improvement of the diagnosis and treatment of this disease.

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

Introduction: Carotid web is an intimal variant of fibromuscular dysplasia, leading to a shelf-like linear defect in the internal carotid bulb. It is a rare, but important embolic etiology for stroke in young patients without conventional cardiovascular risk factors, with a high recurrence rate. Carotid ultrasound is a low-cost, widely available tool in stroke investigation and can be useful as a diagnostic tool for carotid web, as described in this case. Methods: Case report of a patient with recurrent stroke secondary to carotid web, detected by ultrasound, obtained by medical records. Case report: A 57-year-old female patient, with a history of obesity treated with bariatric surgery 7 years ago, presented three episodes of stroke, all in the right anterior circulation. In all of them she presented left side weakness and paresthesia. She remained only with left side paresthesia after those events. The recurrent events happened despite using aspirin and double antiplatelet treatment. A carotid ultrasound was performed and detected a shelf-like, thin band of intima in the posterior wall of the right internal carotid artery. Endarterectomy treatment was performed, and she has been stable ever since with aspirin. Conclusion: Ultrasound is an increasingly available, non-invasive method performed bedside. Although it is a useful diagnostic tool to detect carotid web, it is still a challenging diagnosis, probably due to the lack of awareness among examiners. Given the high rates of stroke recurrence related to carotid web, a careful ultrasound examination and meticulous imaging analysis probably allows earlier diagnosis and appropriate treatment.

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.

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.

Carotid web is a rare and poorly understood condition associated with cryptogenic and recurrent acute ischemic stroke in young patients without atherosclerotic risk factors. We describe the case of a 58-year-old female patient with hypertension and dyslipidemia who had recurrent ischemic strokes for 5 years. Presence of carotid web was suggested by Doppler ultrasonography and confirmed by digital subtraction angiography. The patient underwent endarterectomy and, due to satisfactory internal carotid reflux, it was decided not to use a temporary vascular shunt. Endarterectomy and arteriorrhaphy with a bovine pericardium patch were performed. Although carotid web can be seen with imaging exams, detection can be challenging and it can mimic other conditions, such as arterial dissection, non-calcified atherosclerotic plaque, and intraluminal thrombus. The ease with which it can go unnoticed or misdiagnosed highlights the need to understand this disease.

Introduction : Diagnostic tools for acute ischemic infarcts include the use of DWI sequence on MRI to identify acute infarcts is especially useful since lesions can become hyperintense on this sequence very rapidly (Albers 1998). Over the next 15 days, DWI hyperintensity slowly decreases back to isointense. In some patients, however, there is persistent DWI hyperintensity past 1 month. There are theories that these persistent areas exhibit delayed onset infarct, prolonged ischemia, or perhaps different repair processes (Rivers, et al 2006). To this day, all DWI signals have been known to resolve within a few months even for persistent hyperintensities (Rivers, et al 2006). Carotid webs are a rare form of fibromuscular dysplasia that protrudes from the intimal tissues of carotid arteries. They are shelf‐like projections that grow into the lumen and disrupt normal blood flow (Zhang, et al 2018). These outgrowths are theorized to lead to ischemic strokes due to flow stasis and subsequent embolization of clots that form (Zhang, et al 2018). There is no consensus on the best management of carotid webs, and secondary prevention of recurrent strokes range from medical management to carotid stenting. Methods : This is a case report, and information for the patient was gathered through review of medical records on the EMR. Results : We present a case of ischemic stroke in the right basal ganglia/corona radiata, who presented with left sided weakness. The patient was found to have prediabetes, HTN, and HLD. However, she had recurrence of her symptoms over the next 18 months (figure 1). Repeat MRIs showed persistent DWI hyperintensity that slowly decreased in size and signal intensity over this period but in the same area as the initial infarct. The rest of the work up was only significant for a carotid web in the right internal carotid artery identified on conventional angiography. Ultimately she was managed with medical therapy including aspirin, statin, and antihypertensives. Conclusions : It is unclear whether the carotid web is associated with persistent DWI for such an extended time frame. There is very little research that explores the pathophysiology of ischemic strokes from carotid webs. In addition, there is even less information about the physiology of an evolving infarct that shows persistent DWI signals for such an extended time frame. Further studies that look into carotid webs may help us understand the best long term management in such patients. Future studies that explore the physiology of ischemic strokes that show such persistent DWI signals may elucidate and perhaps expand upon current management options and possibly identify new areas for intervention.

Background: Carotid webs are luminal, shelf-like protrusions at the carotid bulb. Considered to be a variant of fibromuscular dysplasia, carotid webs have been observed principally in African American females. The association between carotid webs and recurrent ischemic strokes continues to be established as patients without traditional stroke risk factors are found to have carotid webs as the only possible cause of symptomatic deficits. The majority of patients undergo endarterectomy; few stent placements are reported. We present the case of an African American female who underwent stent placement for treatment and secondary prevention of stroke attributed to a carotid web. Case Report: A 33-year-old African American female presented with acute onset left hemiparesis and left facial droop. Alteplase was administered; multiphase head and neck computed tomography angiography revealed an occlusion of the right middle cerebral artery with a web at the carotid bulb. Aspiration catheter thrombectomy achieved a Thrombolysis in Cerebral Infarction (TICI) score of 3. She was placed on 2 antiplatelet agents, and 3 weeks later she underwent stent placement. Follow-up digital subtraction angiography at 3 months showed obliteration of the right carotid artery web and satisfactory integration of the stent into the vessel wall. She was reassessed at 1 year and reported no neurologic symptoms. Conclusion: Although carotid webs are most commonly treated with endarterectomy, they may be amenable to stent therapy with favorable clinical outcomes as shown with this patient.

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. 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. 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.

Introduction: Carotid web is a focal variant of fibromuscular dysplasia, creating a septal in the carotid bulb, from which thrombosis can occur and may cause stroke. It is a rare disease and there is not enough evidence to establish optimal treatment. Case report: We report on three patients with carotid web - related strokes: two males (ages 57 and 68) and one female (age 43). Despite optimal medical treatment, both male patients experienced early recurrent strokes, while the female patient presented with a first - time stroke. All three patients underwent carotid stenting, and during a follow - up period of up to 3 years, there were no procedure - related complications or recurrent stroke events. Conclusion: Carotid web is a cause of ischemic stroke with a high risk of recurrence. Carotid stenting is a safe and effective option for long - term prevention of stroke recurrence. There fore, carotid artery imaging should be carefully evaluated, with attention paid to carotid web in patients with cryptogenic stroke.

Case presentation: A 58-year-old Black woman presented with sudden onset aphasia, right-sided weakness, and numbness 11 hours prior to admission at the Emergency Unit. On examination, her NIHSS score was 13, indicating a left middle cerebral artery (MCA) stroke. She had a history of smoking but no other cardiovascular diseases. CT revealed loss of gray-white differentiation in the left insular and frontal regions, with an Alberta Stroke Program Early CT Score (ASPECTS) of 8. CT angiogram of the head showed a left MCA occlusion and a small wedge-shaped hypodense filling defect along the posterior margin of the left internal carotid artery (ICA), suggestive of a carotid web (CW). Thrombolytic therapy was not administered. Endovascular mechanical thrombectomy (MT) using combined use of contact aspiration and stent-retriever technique was performed, achieving successful recanalization (TICI score 3) within 124 minutes Door-to-Recanalization time. The NIHSS score after the procedure was 17. Blood tests, transthoracic echocardiography, continuous ECG monitoring and evaluation for hypercoagulability testing and vasculitis was performed to investigate the etiolgy. Subsequent CT at 24 hours showed hypodensity in the left deep nuclei and left frontoparietal areas and left hyperdense MCA sign. Carotid doppler ultrasound (CDUS) revealed a hypoechoic mass, suggestive of acute thrombus formation on the CW. Cerebral angiography performed prior to carotid angioplasty, identified reocclusion of the ipsilateral MCA. Due to the risk of hemorrhagic complications, a second MT was not performed. The patient was treated with aspirin 300 mg and clopidogrel 75 mg, followed by angioplasty with stent placement 10 days post-stroke. She was subsequently transferred to a stroke rehabilitation center, the NIHSS score was 14 and the RANKIN score was 4. Discussion: Carotid web is a recognized cause of cryptogenic stroke. Our findings are consistent with previous studies describing a higher prevalence of CW in young Black female patients, often ipsilateral to ischemic strokes of undetermined cause. Symptomatic CW is associated with a high rate of recurrent stroke (17% to 40%), particularly in cases involving morphological and hemodynamic changes such as local flow turbulence or in situ thrombus formation. Acute CW thrombosis and early reocclusion following successful MT are rarely reported. Early neurological deterioration (within 3 days) and hemodynamic disturbances related to CW are important red flags in these cases. Follow-up with CDUS may be useful for monitoring thrombus formation. Carotid stenting immediately after MT could be considered to prevent recurrent strokes given the elevated short-term risk post-MT. Final comments: The optimal management to prevent recurrent stroke in patients with carotid web remains uncertain. Observational studies generally favor interventional therapy over medical management, but randomized trials are needed to provide more definitive guidance.

The endothelialization on carotid web treated with dual layer stent placement: a case report