Multimodality imaging of carotid web: A case report and literature review

Abstract

Objectives The carotid web is a compelling potential mechanism of cryptogenic stroke. It is easy for it to escape diagnosis or be misdiagnosed, since it rarely causes hemodynamic stenosis. Currently, there is a lack of consensus on the prevalence, etiology, imaging evaluation, and treatment strategy of carotid artery. We aimed to present the multimodal imaging of carotid web and comprehensively review the characteristics of carotid web. Methods A 38 year-old man with carotid web, who presented with acute left hemispheric syndrome, was not identified by computed tomography angiography and high-resolution magnetic resonance imaging in the initial report, but were identified in retrospect and then confirmed by digital subtraction angiography and histopathology. A literature review of carotid web was performed to identify prevalence, nature history, imaging tools, and optimal management of carotid web. Results 80 reports including 681 patients with carotid web were identified. The prevalence of symptomatic carotid web was 1.2% in patients with transient ischemic attack/stroke, 6.4% in patients with cryptogenic ischemic stroke, 1.1% in patients with large vessel occlusion stroke, and 4.4% in patients who operated on for carotid stenosis. A total of 23.0% patients had bilateral carotid web. In most patients, carotid web was located on the posterior wall (87.3%) of the carotid artery (98.7%). The mean length was 3.3 mm and mean stenosis rate was 20.9%. A total of 31.6% percent patients had thrombus trapped in carotid web and 75.9% patients had large vessel occlusion. Computed tomography angiography and digital subtraction angiography were favorable tools to detect carotid web. There were rare periprocedural complications and no recurrent strokes in carotid revascularization patients. Conclusions carotid web is an under-recognized cause of ischemic stroke. It is easy to be missed or misdiagnosed. Carotid revascularization can effectively prevent recurrent stroke for patients with symptomatic carotid web. Clinicians should strength their learning and understanding of carotid web.

Advances in differential diagnosis of cerebrovascular diseases in magnetic resonance imaging: a narrative review

“…Carotid stenosis often results in TIA or stroke when pieces of plaque get into the brain, and subsequently temporal or permanent signs of cerebral ischemia. Carotid stenosis should be differentiated from carotid web and carotid dissection in diagnosis (93)(94)(95).…”

Sensitivity and Accuracy of Doppler Ultrasound Compared to CT Angiography for the Diagnosis of Carotid Webs: Systematic Review

“…Histopathology, it resembles fibromuscular dysplasia, suggesting that CaW may be an intimal variant of this condition [1]. CaWs are usually unilateral, although bilateral webs have also reported [3].…”

“…The prevalence of CaW in the general population is unknown. Its frequency has been reported to vary between 1.2% and 37% in patients with cryptogenic ischemic stroke [1,3], being more frequent than in control groups [2]. Currently, nonstenotic atherosclerotic disease is thought to be the main mechanisms in embolic stroke of unknown source (ESUS) patients [4].…”

“…Blood flow turbulence and stasis are the main pathophysiological mechanisms predisposing to thrombosis and subsequent emboli in patients with CaW. Stroke recurrence in the same vascular territory of a symptomatic web is reported to be around 25-36% [1,3]. Limited data are available on secondary stroke prevention for CaW as there are no randomized clinical trials.…”

“…A 33% recurrence rate of ischemic stroke in CaW was reported in patients treated with antithrombotic therapy [1]. Carotid surgery or stenting has also been performed and seems to be associated to a reduced recurrence rate [1,3,7]. The recurrence rate drops to 0% when CaW is surgically treated [3,7] and carotid stenting poses as a feasible and relatively safe procedure [1].…”