Treatment Of Symptomatic Carotid Web In The Setting Of Ipsilateral Eagle Syndrome
James J. O'Leary, BS, William D. Mitchell, MD, Philip A. Rivera, MD, Christian P. Hasney, MD, Clayton J. Brinster, MD.
Ochsner Medical Center, New Orleans, LA, USA.
DEMOGRAPHICS: A 63-year-old man presented after two left hemispheric embolic strokes in the presence of minimal left carotid artery stenosis. HISTORY: The patient had a past medical history of hypertension, hyperlipidemia, gout, and left sided Eagle Syndrome. He was non-adherent to anti-hypertensive medication and was a former smoker. He had no history of stroke or thrombosis. He presented to an outside hospital emergency department after two episodes of dysarthria that self-resolved. MRI showed multiple acute infarcts of the left putamen and periventricular subcortex. CTA demonstrated a left carotid web (CW) and severe hypertrophic calcification of the left stylohyoid (Figure 1). Appropriate medical therapy was initiated, and the patient was referred to a higher level of care for surgical planning. PLAN: Combined left stylohyoid osteotomy and left carotid endarterectomy were planned, as direct surgical access to the carotid artery was anatomically impossible given the overlying pathologic stylohyoid. Carotid stenting was deemed unsafe given the potential for stent fracture by the intimately associated, hypertrophied, overlying stylohyoid with neck movement. The concurrent procedures were performed though a single, transverse, left neck incision. A CW was resected from the posterolateral wall of the carotid bulb using sharp dissection. The patient had an uneventful neurologic recovery and remained at baseline one month postoperatively. DISCUSSION: To our knowledge, the concurrent presentation and surgical management of these rare conditions has not been reported. Eagle syndrome, or styloid-carotid artery syndrome, is a rare disorder involving an elongated styloid and/or ossified stylohyoid ligament that may interfere with the vasculature. It may mechanically compress or obscure the surgical exposure of the carotid artery. Surgical resection of the stylohyoid is essential for definitive management and safe exposure. Accurate diagnosis of symptomatic CW, a shelf-like projection of intimal fibrous tissue extending into the carotid bulb, requires a high clinical index of suspicion after cryptogenic stroke in the presence of minimal carotid stenosis. Detailed review of available angiographic or cross-sectional imaging is essential to avoid misdiagnosis and recurrent stroke. In the presence of ipsilateral Eagle syndrome, combined stylohyoid resection and carotid endarterectomy is safe and effective in treating symptomatic CW.
Back to 2023 Abstracts