Carotid Web Research Articles

Carotid Web Management in Symptomatic Patients: A Case Report and Literature Review

Carotid Web Management in Symptomatic Patients: A Case Report and Literature Review

The Carotid Web: A Rare Abnormality of the Intimal Layer Causing Ischemic Stroke in a Young Female Patient

The Carotid Web: A Rare Abnormality of the Intimal Layer Causing Ischemic Stroke in a Young Female Patient

Carotid web: Pathophysiology, diagnostic, and therapeutic options. A narrative review.

A carotid web (CaWeb), otherwise known as a carotid bulb diaphragm, is a spur of intimal fibrous tissue extending into the carotid bulb. It is a rare, underdiagnosed cause of ischemic strokes in young people. The purpose of this narrative review was to provide an update on CaWebs, highlighting recent evolutions in their management. We undertook a comprehensive literature search on main electronic databases - MEDLINE/PubMed, Cochrane Library, Web of Science, and EMBASE - using a dedicated equation to include studies up to February 13, 2024. We also searched for the most recent guidelines about carotid disease or stroke including CaWeb management. A CaWeb is found in up to 10% of young patients, particularly young women, with severe anterior stroke due to an arterial-arterial embolism from the intra-nidus thrombus. Most patients with a CaWeb have less than 50% stenosis on duplex ultrasound, and diagnosis is mostly obtained by computed tomography angiography. When applying traditional stenosis criteria for symptomatic disease (> 50% stenosis), this highly morbid condition is easily overlooked, leading to recurrent strokes. Antithrombotic treatment is associated with a high recurrence rate of stroke after the index event. The first-line treatment of symptomatic CaWebs is increasingly based on endarterectomy or stenting. The lack of recommendations before 2021 and recent discordant guidelines make CaWeb management complex. No guidelines are available to manage patients with asymptomatic CaWebs. Results from ongoing multicenter registries will be useful in guiding management decisions.

Current Therapy for Carotid Webs

IntroductionCarotid webs are a potential cause of ischemic stroke, particularly in younger patients with few traditional risk factors. Despite advances in imaging technology, the management of carotid webs remains poorly defined due to its rarity, absence of evidence-based guidelines, and the unique challenges presented by these lesions. This narrative review evaluates current knowledge on carotid web management, emphasizing diagnostic features, pathophysiological considerations, and treatment strategies. MethodsA literature search was conducted using PubMed and Google Scholar databases with search terms “carotid web management,” “carotid web treatment,” and “carotid web,” focusing on studies published between 2014 and 2024. ResultsCarotid webs are a variant of fibromuscular dysplasia and represent a potential source of embolic strokes. Despite the low overall prevalence, they account for a significant proportion of strokes in younger patients, with a high risk of recurrence when managed medically. Diagnosis often requires advanced imaging, such as CTA or MRA. Treatment options include medical management, carotid endarterectomy, and stenting, though no consensus guidelines exist. Medical management alone has a high recurrent stroke risk. ConclusionCarotid webs should be included in the differential diagnosis of patients with cryptogenic stroke, particularly in younger individuals. Given the high recurrence rates with medical management, both endarterectomy and stenting are recognized as safe and effective treatment options. Future prospective studies are needed to determine the optimal management strategy, including the role of preoperative anticoagulation and comparative outcomes of different treatment modalities.

Transcarotid arterial revascularization for symptomatic carotid web

ObjectivesSymptomatic carotid web is an increasingly recognized cause of acute ischemic stroke with a high risk of recurrent ischemic events despite aggressive medical interventions. Surgical interventions including transfemoral carotid artery stenting (TFCAS) and carotid endarterectomy have been described to reduce this risk, but transcarotid arterial revascularization (TCAR) has not been evaluated for this purpose. Materials and MethodsPatients with cerebral ischemia from carotid web underwent TCAR with flow reversal. Patients were monitored for periprocedural complications and assessed at follow-up for clinical evidence of recurrent ischemia. ResultsSix cases over the course of 21 months were identified, 2 males and 4 females with a median age of 59.5 (interquartile range of 39). All underwent technically successful TCAR without periprocedural complications no post-procedural cerebral ischemia over a median follow-up time of 21 months. ConclusionsIn this small series of patients, TCAR provided a safe and effective treatment of carotid webs that had previously caused cerebral ischemia.

Treatment of Symptomatic Carotid Webs

The present study aims to describe the clinical characteristics and treatment outcomes of patients with symptomatic carotid web treated at a single institution in South America. Retrospective study of a single-center experience of patients with carotid webs surgically treated from September 2019 to September 2023. 10 patients had carotid webs, six (60%) were females. Median age was 54.5 years (range: 35-77 years). All patients were symptomatic. Diagnosis was made in 90% (n=9) of the patients with either computed tomography angiography or magnetic resonance alone. One (10%) patient underwent angiography for definite diagnosis. The median interval from the first neurological event to intervention was 90 months (range: 3 days- 108 months). Four (40%) patients underwent surgical treatment within one month from symptom onset and carotid web diagnosis, with a median of 3.5 days (range: 3-9 days). Six (60%) patients underwent delayed surgical treatment since the cause of the neurological event was uncertain, with a median of 54 months (range: 6 - 108 months). These six patients had recurrent neurological events. Three (30%) patients underwent carotid endarterectomies with polyurethane patch and three (30%) by eversion technique. Three (30%) patients underwent segmental resection and reanastomosis of the internal carotid artery. One underwent internal carotid artery plasty with saphenous vein. At a median follow-up of 30 months (range: 6-46 months), one patient persists with mild aphasia, another patient has severe aphasia and right hemiparesis, both as sequalae of their initial strokes, and another patient has suffered 3 non-ischemic episodes of brief transient right hemiparesis attributed to epileptic seizures. The other seven patients remain without new neurological events. Neurological events of carotid distribution deserve accurate imaging work up, keeping in mind the diagnosis of carotid web. Surgical treatment for carotid web seems effective for preventing recurrences; nevertheless, further studies are warranted to define the best management for these patients.

Differentiating extradural head and neck arterial fenestrations from other intraluminal abnormalities

Background and PurposeArterial fenestrations are a benign entity arising from a failure of fetal fusion. However, fenestrations in the head and neck may be misinterpreted as carotid webs or dissections. Given differences in clinical management, the differentiation of these entities is imperative. We aim to document the prevalence of these entities on CTA imaging and highlight imaging features for confident differentiation. Materials and MethodsWe retrospectively reviewed head and neck CTA studies performed at our institution over an 18-month period. The extradural common carotid, internal carotid, external carotid, and vertebral arteries were inspected for intraluminal abnormalities. These abnormalities were classified as fenestration, web, or dissection. Location and associated non-atherosclerotic calcification, pseudoaneurysm, or thrombosis were also documented. ResultsA total of 1800 head and neck CTAs were examined. Normal extradural arteries were seen in 1731 patients (1731/1800; 96.2 %). An intraluminal abnormality was evident in the remaining 69 patients (69/1800; 3.8 %). There were 16 carotid webs (16/1800; 0.9 %), 46 dissections (46/1800; 2.6 %), and 7 fenestrations (7/1800; 0.4 %). An associated non-atherosclerotic pattern of calcification was only identified in a single fenestration case (1/7; 14.3 %). Thrombosis was not identified in any fenestration case. ConclusionArterial fenestrations of the extradural head and neck arterial vasculature are evident on 0.4 % of CTAs. It is important to differentiate these benign entities from carotid webs and arterial dissections. With the appropriate knowledge and interpretive tools, characteristic imaging findings on CTA can be used for reliable differentiation.

Spontaneous asymptomatic common carotid artery dissection resembling a carotid web: illustrative case.

Carotid artery dissection is a common cause of ischemic stroke, predominantly affecting the internal carotid artery, with rare involvement of the common carotid artery (CCA). The limited literature makes diagnosis and management challenging, particularly in asymptomatic patients. In this report, the authors present a unique case of spontaneous, asymptomatic CCA dissection that resembled a carotid web, shedding light on its clinical spectrum and management. A 70-year-old man was diagnosed with an intimal flap in the left CCA. Although the findings resembled those of a carotid web, cerebral angiography confirmed the presence of an intimal flap and arterial wall irregularities indicative of vascular dissection. Endarterectomy successfully prevented the stroke, and the postoperative recovery was uneventful. Pathological examination confirmed the diagnosis of CCA dissection. Spontaneous CCA dissection, though rare, presents significant diagnostic and therapeutic challenges. Because of morphological similarities, differentiating the diagnosis from a carotid web can be difficult. Available treatment strategies include antiplatelet therapy and surgical intervention. In this case, endarterectomy was chosen to avoid antithrombic treatment in anticipation of further invasive treatments for other conditions. The successful outcome highlights the potential as a treatment option, emphasizing the need for an individualized approach to each patient. https://thejns.org/doi/10.3171/CASE24344.

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

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. 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. 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). 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.

Relationship between carotid web morphology on CT angiography and stroke: A pooled multicenter analysis.

The Carotid web (CaW) is a cause of stroke, particularly in younger individuals. However, the frequency and the radiological features of the web's morphology associated with stroke risk are uncertain. We determined the CaW radiological features on computed tomography (CT) angiography associated with ipsilateral stroke. Data from six studies of patients with acute ischemic stroke were pooled. Identification and measurement of CaWs were performed by experienced readers using baseline neck CT angiography. We assessed six 2D CaW radiological features on sagittal oblique images, namely, main axis length, thickness, height, base width, distance to wall, and angle between the web main axis and carotid wall, and CaW volume on 3D images. CaWs were divided into symptomatic if acute ischemic stroke was in the ipsilateral internal carotid artery territory and its etiology was undetermined and asymptomatic if one condition was unmet. Univariable and multivariable analyses were conducted to assess the association between each radiological CaW feature and symptomatic CaW. Of the 3442 patients in the pooled data with assessable CTAs, 60 (1.7%) had CaW. In patients with CaW, median age was 59 (interquartile range [IQR]: 50-68) years, 60% were women, and 3 patients had bilateral CaWs. There were 39 (62%) symptomatic and 24 (38%) asymptomatic CaWs. Patients with symptomatic CaW were younger (55 (IQR: 49-61) years versus 69 (IQR: 52-75) years), had lower rates of hypertension (9 (25.0%) versus 12 (57.1%)) and more intracranial large vessel occlusions compared to patients with asymptomatic CaWs. After adjusting for age, hypertension, and occlusion location, CaW length (adjusted odds ratio (aOR) 1.84 (95% confidence interval [CI]: 1.03-3.28)), thickness (aOR: 2.31 (95% CI 1.08-4.97)), volume (aOR: 1.07 per 1 mm3 increment (95% CI: 1.01-1.12)), and angle relative to the carotid wall (aOR: 0.95 (95% CI: 0.91-0.99)) were associated with symptomatic CaW. Radiological assessment of CaW morphology may determine its potential causal role in ischemic stroke etiology. Symptomatic CaWs tend to be longer, larger, and oriented at more acute angles relative to the carotid wall as compared to asymptomatic CaWs.

Symptomatic carotid webs and patent foramen ovale: RoPE score in competing stroke etiologies

BackgroundPatent foramen ovale (PFO)-associated stroke is diagnosed more frequently in young patients with infrequent vascular risk factors and embolic appearing infarcts. The risk of paradoxical embolism (RoPE) score is used to identify PFO-associated stroke. Patients with symptomatic carotid artery web (CaW) share a very similar risk profile and these lesions are frequently overlooked. In this study, we evaluate the RoPE score profile in patients with suspected symptomatic CaW. MethodsRetrospective analysis of prospectively collected data of patients with symptomatic CaW as the presumed cause of stroke presenting to 2 comprehensive stroke centers from 2014 to 2021. CaW was diagnosed using computed tomography angiography (CTA) of the neck & head. Shunt study was done using a transthoracic, transesophageal, and/or transcranial-Doppler with bubbles. RoPE score ≥7 was considered high. ResultsSeventy-five patients had stroke from a symptomatic ipsilateral CaW. Mean age was 49.7±11.2 years and 74.7 % were females. Median RoPE score was 7 [5–8], and 52.0 % had a high RoPE score. PFO was detected in 13.3 % of the patients and 20.5 % within the high RoPE score group. Ten percent of the cases would have been misclassified as PFO-associated strokes based on RoPE score. ConclusionHigh RoPE scores were observed in the majority of patients with CaW-attributed stroke, and it should not be used to differentiate CaW- versus PFO-associated stroke. Careful extracranial internal carotid artery evaluation for CaW is warranted in cryptogenic strokes, including in PFO positive patients before defining stroke etiology.

Reversible Cerebral Vasoconstriction Syndrome And Fibromuscular Dysplasia: An Epiphenomenon Or A Causal Relationship?

Abstract Fibromuscular dysplasia (FMD) is a rare non-atherosclerotic arterial disease that primarily affects middle-aged Caucasian women. Carotid web (CW) is a variant of FMD characterized by a non- atheromatous, membrane-like tissue protrusion into the carotid bulb. Reversible cerebral vasoconstriction syndrome (RCVS) is defined by severe headaches and reversible narrowing of cerebral arteries, which typically resolves within three months. While most RCVS cases have identifiable triggers, a significant portion occurs without known causes. Recent studies have reported a high prevalence of neurovascular abnormalities in RCVS patients. We present a case of a thirty-year-old woman with a sudden-onset severe headache, diagnosed with RCVS associated with carotid web. The patient had no ischemic involvement and responded well to flunarizine treatment. Follow-up imaging showed no stenosis. This case highlights a potential association between carotid web and RCVS, suggesting that FMD may contribute to vascular hyperreactivity and presents as a risk factor for RCVS. Further investigations are needed to understand the underlying mechanisms connecting these two vascular disorders.

Multiplane reconstruction modifies the diagnostic performance of CT angiography in carotid webs

IntroductionCarotid Web (CaW) represents an overlooked stroke etiology and has been associated with high recurrence rates and to be amenable to stenting. We evaluated the diagnostic performance of different computed tomography angiography (CTA) projections in CaW. MethodsConsecutive patients <65 years-old with symptomatic CaW (n=31), carotid atherosclerosis (n=27), or normal carotids (n=49) diagnosed with a thin-cut CTA were included. Deidentified CTAs were independently reviewed by three readers, who recorded the diagnosis and level of certainty after evaluating the axial plane alone, after adding sagittal/coronal maximum intensity projection (MIP), then after oblique MPR reformats. ResultsThere were 93 total CaW, 81 atherosclerosis, and 147 normal carotid reads. With CTA axial projection alone, less CaW cases (44.1 %) were appropriately diagnosed as compared to atherosclerosis (87.7 %; p<0.001) and normal carotid (83 %; p<0.001) cases. Sagittal/coronal MIPS increased the rate of accurate CaW diagnosis (44.1–76.3 %; p<0.001). Inter-rater agreement in CaW detection increased from k= 0.46 (0.35–0.57) using axial to k= 0.80 (0.69–0.91) with sagittal/coronal planes. The axial projection alone had lower sensitivity (44 % vs. 76 %) but similar specificity (95 % vs. 96 %) in CaW detection compared to axial+ sagittal/coronal MIPS. The accuracy in detecting atherosclerosis or normal carotids did not increase after adding sagittal/coronal MIPS and oblique MPRs. The certainty level for CaW diagnosis was lower when compared to atherosclerosis and normal carotids using axial alone (3.0 [3.0–4.0] vs. 4.0 [3.0–5.0]; p<0.001 and 4.0 [3.0–5.0]; p<0.001) as well as after adding sagittal/coronal MIPS (4.0 [3.0–5.0] vs. 5.0[4.0–5.0]; p=0.01 and 4.0 [4.0–5.0]; p<0.001). ConclusionCTA axial plane alone was insufficient for CaW detection. CTA sagittal/coronal MIP reconstructions as well as oblique MPR reformats enhanced the accuracy and confidence related to CaW diagnosis.

Treatment of Symptomatic Carotid Webs: A Single-Center Review

IntroductionCarotid 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). MethodsWe 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. ResultsFifteen patients presented with carotid web and stroke from 2020-2023 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. DiscussionWe discuss our experience of carotid web and its management as well as review of the current literature.

Intravascular Ultrasound-guided Carotid Artery Stenting in Carotid Web Suspicion: Its Role on Diagnosis and Treatment of this Infrequent Condition

Intravascular Ultrasound-guided Carotid Artery Stenting in Carotid Web Suspicion: Its Role on Diagnosis and Treatment of this Infrequent Condition

Floating Thrombosis on a Carotid Web.

Floating Thrombosis on a Carotid Web.

Assessment of Complex Flow Patterns in Patients With Carotid Webs, Patients With Carotid Atherosclerosis, and Healthy Subjects Using 4D Flow MRI

Assessment of Complex Flow Patterns in Patients With Carotid Webs, Patients With Carotid Atherosclerosis, and Healthy Subjects Using <scp>4D</scp> Flow <scp>MRI</scp>

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.

Risk Factor Profile with Carotid Web in Young Stroke (P11-5.002)

Risk Factor Profile with Carotid Web in Young Stroke (P11-5.002)

Fubuki XF Long Sheath guide catheter use in neuroendovascular procedures: Institutional experience in 60 cases.

Endovascular treatment devices require compatible guide catheters to navigate complex vessels and anatomy. The Fubuki XF Long Sheath guide catheter (Fubuki XF) was developed with a 0.090-inch internal diameter with hydrophilic coating, an atraumatic rounded tip, and enhanced trackability and support with gradual shaft transition zones. We retrospectively analyzed a prospectively maintained database of neuroendovascular patients treated using Fubuki XF at our center (July 2022─May 2023). Baseline/procedural characteristics were collected. Outcomes of interest included technical success (procedure completion with Fubuki XF without alternative guide catheter use) and peri-procedural complications. This study included 60 patients (43.3% [26/60] female; mean age: 69.6 ± 9.7) presenting with stenosis (45.0% [27/60]), unruptured aneurysms (31.7% [19/60]), ruptured aneurysm (1.7% [1/60]), arteriovenous fistula (5.0% [3/60]), arteriovenous malformation (3.3% [2/60]), chronic subdural hematoma (3.3% [2/60]), stroke/emboli (6.7% [4/60]), vasospasm (1.7% [1/60]), or carotid web (5.0% [1/60]). Fubuki XF was used to deliver endovascular treatment devices for stenting (43.3% [26/60]), flow diversion (23.3% [14/60]), embolization (11.7% [7/60]), coiling (10.0% [6/60]), balloon angioplasty (10.0% [6/60]), and mechanical thrombectomy (1.7% [1/60]). The Fubuki XF tip was placed in the internal carotid artery in 38.3% (23/60) of cases. Technical success was achieved in all cases. One V1 non-flow-limiting dissection (not related to Fubuki XF) and one failed closure occurred (1.7% [1/60] each). No iatrogenic strokes or intraprocedural ruptures occurred. We used Fubuki XF to safely and effectively deliver a variety of compatible neuroendovascular devices. Fubuki XF was stable in all cases and locations, and there were no device-related complications or dissections.