Diaphragms of the carotid and vertebral arteries: an under‐diagnosed cause of ischaemic stroke

Abstract

Diaphragms are a rare cause of recurrent embolic strokes which are often not detected with non-invasive imaging. Stenting appears to be a therapeutic option in stroke secondary prevention. These observations suggest that conventional angiography should be performed in cases of recurrent ischaemic strokes in the territory of a single artery and in cases of ischaemic stroke of undetermined aetiology in young adults when the usual investigations are negative.

Carotid Stenting for Treatment of Symptomatic Carotid Webs: A Single-Center Case Series

“…Four case series and case reports with a total of 21 patients have reported outcomes of carotid web stenting in patients with symptomatic lesions (Table 1) [4, 8-10]. The largest study to date included 16 patients [8].…”

“…Stroke recurrence rates in this patient population are high, up to 25–35%, even with antiplatelet therapy [2, 3]. Prior small series and case reports have reported variable outcomes with aggressive medical management (i.e., dual antiplatelet therapy), carotid endarterectomy, and even carotid stenting as strategies to reduce stroke recurrence rates in this patient population [1-4]. Herein, we report our single-center experience with carotid stenting for treatment of carotid webs.…”

Carotid-Bulb Atypical Fibromuscular Dysplasia in Young Afro-Caribbean Patients With Stroke

“…Inclusion criteria were age ≤55 years, defining young; nonlacunar carotid-territory infarction downstream from CaFMD; CaFMD as described above on computed tomographic angiography (CTA) images; no other stroke cause after comprehensive work-up, including brain MRI within 48 hours, transthoracic and transesophageal echocardiographies, 24-hour ECG Holter, routine biological tests, carotid and vertebral duplex ultrasound (DUS) and extracranial artery CTA; and no evidence of calcification or patent atherosclerosis of extraor intracranial arteries. This 5-year study had 2 phases: during part 1 (January 2008 to October 2011), CTA was done only when DUS visualized an echogenic bulbar outgrowth in the proximal internal carotid 5 ; during part 2 (November 2011 to February 2013), CTA was done systematically, regardless of DUS findings (if done). In addition, because of the observed high stroke-recurrence rate, despite antiplatelet therapy, and with local Ethics Committee approval, surgical CaFMD removal was proposed for incident and recurrent ischemic events, during part 2.…”

“…Another type of FMD, called septae, diaphragm, or atypical FMD has been reported anecdotally, mainly in blacks 2,3 or in Asians. 4 Atypical FMD is focal, located in the carotid-bulb (CaFMD) or, more rarely, the vertebral artery, 5 predominantly involves the intima, and its angiographic image resembles a spur, usually on the posterolateral side of a megabulb. 2 Curiously, all but one 5 report on CaFMD are not recent, which might explain our suboptimal knowledge about this cause of stroke affecting the young and potentially recurrent.…”

“…4 Atypical FMD is focal, located in the carotid-bulb (CaFMD) or, more rarely, the vertebral artery, 5 predominantly involves the intima, and its angiographic image resembles a spur, usually on the posterolateral side of a megabulb. 2 Curiously, all but one 5 report on CaFMD are not recent, which might explain our suboptimal knowledge about this cause of stroke affecting the young and potentially recurrent. 6,7 Because Martinique, a French West Indies island, is inhabited mostly by Afro-Caribbeans, we expected to find CaFMD responsible for ischemic strokes in young Martinicans.…”