Carotid Web Is An Under Recognized And Devastating Cause Of Ischemic Stroke
Clayton J. Brinster, MD, Gabriel Vidal, MD, Hernan Bazan, Ross Parkerson, MD, Charles Leithead, MD, Samuel Money, MD, W.C. Sternbergh, III, MD.
Ochsner Clinic Foundation, New Orleans, LA, USA.
OBJECTIVES: Carotid web is a rare form of fibromuscular dysplasia that can result in embolic stroke. Misdiagnosis is common and can lead to catastrophic neurologic events. Reports in the literature are scarce, and management remains controversial.
METHODS: Carotid web was defined as single, shelf-like, linear projection in the carotid bulb causing a characteristic filling defect on CTA or angiography (Figure). Cases at a single institution with a high-volume stroke center were identified retrospectively.
RESULTS: Between 2016 and 2020, a total of 38 webs were identified in 32 patients - 22 (69%) were women. Average age was 48 years; 23 (72%) were African-American. Symptomatic patients (26/32; 81%) initially presented with stroke (23/26; 88%) or TIA (3/26; 12%). Webs were found incidentally in 6/32 (19%). Notably, the degree of stenosis was <50% in all patients, none were diagnosed with carotid ultrasound, and 16/26 (62%) symptomatic webs were missed on initial CTA or cerebral angiography. Web-associated thrombus was observed radiographically or grossly upon carotid exploration in 13/26 (50%) symptomatic patients (Figure). Seven patients (27%) had a history of cryptogenic stroke and presented with ipsilateral recurrence at an average interval of 28 months. All seven were on dual antiplatelet and statin therapy prior to recurrence - four were left with permanent deficits. Definitive treatment in symptomatic patients was with trans-femoral stenting in 19/25 (76%) or endarterectomy in 6/25 (24%). After an average follow-up of 19 months, there has been no reported stroke or mortality following intervention. Six patients with asymptomatic webs have been managed with antiplatelet and statin therapy for an average of 20 months.
CONCLUSIONS: As the largest experience reported to date, our series demonstrates that carotid web is often missed on carotid duplex, CTA, and cerebral angiography, and that devastating neurologic events occur if treatment is delayed after initial, web-related stroke. Symptomatic patients warrant aggressive intervention, as recurrent stroke occurred in all who were managed with medical therapy alone after initial ipsilateral stroke. A high index of suspicion and rigorous review of imaging are essential for accurate diagnosis, especially in younger, African-American women who present with cryptogenic stroke and minimal carotid stenosis.
Back to 2021 Abstracts