March 24, 2022
A 47-year-old woman with no identified cardiovascular risk factors presents to the emergency department with left-sided hemiparesis, numbness, facial drooping, and dysarthria.
Carotid Web and Ischemic Stroke
- Background:
- A carotid web is a shelflike filling defect that projects into the carotid bulb lumen. It is histologically defined as an intimal variant of fibromuscular dysplasia.
- Disrupted blood flow in the area immediately superior to a carotid web contributes to thrombus formation and subsequent cerebral embolism.
- Clinical Presentation:
- Patients are typically asymptomatic, but some may present with recurrent ipsilateral ischemic strokes or transient ischemic attacks.
- Carotid webs are rare, with an estimated prevalence of 1.2%. However, they may contribute to up to 21.2% of cryptogenic ischemic strokes.
- There is a higher incidence in young women with no other identifiable stroke risk factors.
- Key Diagnostic Features:
- On an oblique sagittal CTA section, it appears as a smooth, thin, and linear intraluminal lesion, characteristically arising from the posterior intimal wall of the carotid bulb.
- On an axial CTA section, it has a septal appearance.
- Differential Diagnoses:
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Carotid artery dissection: Intimal flap or double lumen appearance; tends to comprise a long segment of the internal carotid artery; occurs distal to a preserved carotid bulb; associated with mural hematoma formation and pseudoaneurysmal dilatation; history of head or neck trauma
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Atherosclerotic plaque: Typically involves short-segment stenosis of the carotid bifurcation and bulb; associated with focal intramural thickening and calcifications; cardiovascular risk factors, such as hypertension, dyslipidemia, diabetes mellitus, or smoking
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Typical fibromuscular dysplasia: “String of beads” appearance from vessel irregularities; involves tunica media of multiple medium-sized arteries, particularly the renal arteries; spares the carotid bifurcation; associated with vascular ectasia or stenosis without mural calcification
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Treatment:
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There is no standardized treatment for prevention of strokes attributable to carotid webs.
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The most common management strategies currently include antiplatelet therapy.
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Carotid endarterectomy and minimally invasive endovascular stenting have shown good results for recurrent strokes.
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