Thromboembolism from Carotid Web.

Abstract

HomeRadiologyVol. 306, No. 3 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyThromboembolism from Carotid WebNoel F. Fanning , Brian J. ManningNoel F. Fanning , Brian J. ManningAuthor AffiliationsFrom the Departments of Neuroradiology (N.F.F.) and Vascular Surgery (B.J.M.), Cork University Hospital, Wilton, Cork, Ireland.Address correspondence to N.F.F. (email: [email protected]).Noel F. Fanning Brian J. ManningPublished Online:Nov 15 2022https://doi.org/10.1148/radiol.221504MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In A 26-year-old woman presented with 5 hours of acute right neck pain and left arm weakness after exercising. At examination, her National Institutes of Health Stroke Scale score was 3, indicating mild deficits. MRI scans showed a right middle cerebral artery (MCA) infarct (Figure, A), and CT head angiogram showed a right MCA occlusion (not shown in Figure). The patient did not receive thrombolytic therapy due to time from symptom onset. She was transferred to a comprehensive stroke center for further management. Subsequent CT head angiogram showed spontaneous recanalization of the right MCA occlusion (not shown in Figure). CT carotid angiogram revealed shelf-like protrusion from the dorsal aspect of the internal carotid artery just beyond the bifurcation, diagnostic of a carotid web (Figure, B). A carotid endarterectomy (CEA) was performed, showing a firm pale protrusive web from the dorsal internal carotid artery (Figure, C) matching the CT angiogram appearance. Histologic findings showed spindle cells and myxoid degeneration (Figure, D) and no features of atherosclerotic plaque.Images in a 26-year-old woman with acute stroke symptoms. (A) Axial diffusion-weighted MRI scan shows an acute right middle cerebral artery territory infarct. (B) Sagittal CT right carotid angiogram shows a shelf-like protrusion from the dorsal aspect of the internal carotid artery (ICA) just beyond the bifurcation (arrow), diagnostic of a carotid web. (C) Intraoperative photograph shows the opened right ICA with a firm pale protrusive web from the dorsal ICA (arrow) matching the CT angiogram appearance. The asterisks in B and C indicate the external carotid artery for orientation. (D) Hematoxylin and eosin stain of the web show myxoid degeneration (arrow) and no features of atherosclerotic plaque.Download as PowerPointOpen in Image Viewer This patient example illustrates the appearance of carotid webs, an underrecognized cause of stroke. Carotid webs represent an intimal variant of fibromuscular dysplasia. In patients presenting with large vessel occlusions, carotid webs are seen in 1% of cases ipsilateral to the index ischemic stroke. Recurrent stroke occurs in 17% of patients with symptomatic carotid webs within 2 years, despite medical management, compared with 3% recurrence rate without carotid webs (1). Optimal management strategies for carotid webs are yet to be defined. Medical management, carotid endarterectomy, or carotid stenting should be considered as part of a multidisciplinary discussion. The patient has remained well 8 months after CEA, with no residual deficits or recurrent stroke symptoms.Disclosures of conflicts of interest: N.F.F. No relevant relationships. B.J.M. No relevant relationships.