Carotid Webs: Radiographic Appearance and Significance

Wojcik, Kyle; Milburn, James; Vidal, Gabriel; Steven, Andrew

doi:10.31486/toj.18.0001

Cited by 19 publications

(26 citation statements)

References 14 publications

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“…Additional work with even larger numbers of patients would be needed to confirm this association because this was identified in only a handful of patients and the prevalence of webs in a typical population is around 1%. 25,[28][29][30] While prior work has found the presence of carotid dissection in SCAD to be in the range of 2.5%-5%, the current study demonstrates a prevalence of more than twice that, suggesting that dissection is more common than previously suspected. 31,32 Nonetheless, the relatively low prevalence of dissection compared with FMD at a single time point examination in the current study may provide some reassurance of cerebrovascular risk for patient counseling for many patients.…”

Section: Discussioncontrasting

confidence: 64%

Prevalence of Cervical Artery Abnormalities on CTA in Patients with Spontaneous Coronary Artery Dissection: Fibromuscular Dysplasia, Dissection, Aneurysm, and Tortuosity

Benson

Lehman

Verdoorn

et al. 2021

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE:Little is known about associations between spontaneous coronary artery dissection and cervical artery abnormalities. This study sought to assess the prevalence of cervical artery abnormalities among patients with spontaneous coronary artery dissection. MATERIALS AND METHODS:A retrospective analysis was completed of patients who underwent CTA neck imaging as part of arterial assessment following the diagnosis of spontaneous coronary artery dissection. The internal carotid and vertebral arteries were evaluated for the presence of fibromuscular dysplasia, dissection and/or pseudoaneurysm, ectasia and/or aneurysmal dilation, atherosclerosis, and webs. Carotid tortuosity was categorized into kinks, loops, coils, and retrojugular and/or retropharyngeal carotid courses; vertebral tortuosity was classified by subjective analysis of severity.RESULTS: Two hundred fourteen patients were included in the final cohort, of whom 205 (95.8%) were women; the average age was 54.4 years. Fibromuscular dysplasia was the most frequently observed abnormality (83 patients; 38.8%), followed by dissections and/or pseudoaneurysms (n ¼ 28; 13.1%), ectasia and/or aneurysmal dilation (n ¼ 22; 10.3%), and carotid webs (n ¼ 10; 4.7%). At least 1 type of carotid tortuosity was present in 99 patients (46.3%). The majority (n ¼ 185; 86.4%) of patients had no carotid atherosclerosis; and 26 (12.2%) had mild; 3 (1.4%), moderate; and 0, severe carotid atherosclerosis. CONCLUSIONS:The most common abnormality in the cervical artery vasculature of patients with spontaneous coronary artery dissection is fibromuscular dysplasia. Cervical dissections were higher than previously reported but were not observed in most patients. ABBREVIATIONS: ACS ¼ acute coronary syndrome; CTD ¼ connective tissue disorder; FMD ¼ fibromuscular dysplasia; SCAD ¼ spontaneous coronary artery dissection S pontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), predominantly affecting otherwise healthy young and middleaged women. 1,2 By definition, it refers to dissection of the coronary artery wall in the absence of trauma, atherosclerosis, or iatrogenic causes. 3 The resultant intramural hematoma and/or intimal flap can cause substantial luminal narrowing, leading to myocardial ischemia and infarction. Once considered rare, SCAD is now thought to be the cause of up to 4% of cases of ACS and up to 35% of cases of ACS in women younger than of 50 years of age. 4,5 Furthermore, there is evidence that the incidence of SCAD has increased during the past decades. 6

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Section: Discussioncontrasting

confidence: 64%

Prevalence of Cervical Artery Abnormalities on CTA in Patients with Spontaneous Coronary Artery Dissection: Fibromuscular Dysplasia, Dissection, Aneurysm, and Tortuosity

Benson

Lehman

Verdoorn

et al. 2021

AJNR Am J Neuroradiol

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“…2 Since that time, carotid webs have been described as nonatherosclerotic fibrous bands that arise along the posterior margin of the carotid bulb. 3-7…”

Section: Introductionmentioning

confidence: 99%

Survey of Current Management Practices for Carotid Webs

Wojcik

Milburn

Vidal

et al. 2019

TOJ

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Background: Carotid webs are thick, fibrous intimal bands that appear as intraluminal shelf-like defects at the carotid bifurcation on vascular imaging. These lesions are a potential underrecognized cause of cryptogenic ischemic stroke. Although the recognition of carotid webs has increased, no evidence-based treatment guidelines are available. We surveyed subspecialists across multiple neurologic disciplines to assess the state of current clinical practice.Methods: An 8-question multiple-choice style survey of neurologists and radiologists assessed familiarity with this disease entity, preferred imaging modalities, and management strategies for asymptomatic and symptomatic (producing stroke) carotid webs. Responses were collected through SurveyMonkey software via anonymous responses to a posted survey link on the Society of Neurointerventional Surgery website in addition to invitation emails sent to colleagues in corresponding fields.Results: Of the 74 total respondents, 64% identified as neurointerventionalists. Respondents identified computed tomography angiography as the most commonly used imaging modality to place carotid webs in the differential diagnosis (57% of respondents’ preference), while conventional digital subtraction angiogram was the preferred modality to confirm a web (54% of respondents’ preference). Respondents preferred single and dual antiplatelet therapy to manage asymptomatic and acute stroke-producing carotid webs, while invasive treatment was most commonly sought for webs producing recurrent strokes.Conclusion: Familiarity with carotid webs varied across subspecialties. We found some consensus among respondents on the imaging modality preferred to identify webs, on asymptomatic carotid web management, and on recurrently symptomatic (multiple strokes) carotid web management. Less consistency was seen regarding preferences for confirmatory imaging and management of acutely symptomatic (initial stroke) carotid webs.

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“…Complex cases were presented at our multidisciplinary conference (stroke neurology, neuroradiology, neurointerventional radiology, and vascular neurosurgery). Because the degree of stenosis in CW patients does not predict stroke risk, 6,7 it did not significantly impact our management decisions and we opted for CEA of the lesions. Preoperative assessment of the contralateral carotid artery as well as the circle of Willis was performed according to either formal angiography or CTA, in order to assess risk of carotid trapping during CEA as well as the level of the bifurcation and other anatomical factors that could affect the surgical approach.…”

Section: Clinical Management and Surgical Approachmentioning

confidence: 99%

“…5 Notably, the amount of stenosis attributed to the presence of a web is not a significant predictor of stroke risk. 6,7 CWs may be easily missed on routine diagnostic workup for ischemic stroke as they only rarely cause hemodynamically significant stenosis and can ABBREVIATIONS ACT = activated clotting time; CAS = carotid artery stenting; CEA = carotid endarterectomy; CTA = CT angiography; CW = carotid web; DSA = digital subtraction angiography; FMD = fibromuscular dysplasia; SMA = smooth muscle actin.…”

mentioning

confidence: 99%

Endarterectomy for symptomatic internal carotid artery web

Haynes

Raz

Tanweer³

et al. 2020

Journal of Neurosurgery

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OBJECTIVEThe carotid web (CW) is an underrecognized source of cryptogenic, embolic stroke in patients younger than 55 years of age, with up to 37% of these patients found to have CW on angiography. Currently, there are little data detailing the best treatment practices to reduce the risk of recurrent stroke in these patients. The authors describe their institutional surgical experience with patients treated via carotid endarterectomy (CEA) for a symptomatic internal carotid artery web.METHODSA retrospective, observational cohort study was performed including all patients presenting to the authors’ institution with CW. All patients who were screened underwent either carotid artery stenting (CAS) or CEA after presentation with ischemic stroke from January 2019 to February 2020. From this sample, patients with suggestive radiological features and pathologically confirmed CW who underwent CEA were identified. Patient demographics, medical histories, radiological images, surgical results, and clinical outcomes were collected and described using descriptive statistics.RESULTSA total of 45 patients with symptomatic carotid lesions were treated at the authors’ institution during the time period. Twenty patients underwent CAS, 1 of them for a CW. Twenty-five patients were treated via CEA, and of these, 6 presented with ischemic strokes ipsilateral to CWs, including 3 patients who presented with recurrent strokes. The mean patient age was 55 ± 12.6 years and 5 of 6 were women. CT angiography or digital subtraction angiography demonstrated the presence of CWs ipsilateral to the stroke in all patients. All patients underwent resection of CWs using CEA. There were no permanent procedural complications and no patients had stroke recurrence following intervention at the latest follow-up (mean 6.1 ± 4 months). One patient developed mild tongue deviation most likely related to retraction, with complete recovery at follow-up.CONCLUSIONSCEA is a safe and feasible treatment for symptomatic carotid webs and should be considered a viable alternative to CAS in this patient population.

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Carotid Webs: Radiographic Appearance and Significance

Cited by 19 publications

References 14 publications

Prevalence of Cervical Artery Abnormalities on CTA in Patients with Spontaneous Coronary Artery Dissection: Fibromuscular Dysplasia, Dissection, Aneurysm, and Tortuosity

Prevalence of Cervical Artery Abnormalities on CTA in Patients with Spontaneous Coronary Artery Dissection: Fibromuscular Dysplasia, Dissection, Aneurysm, and Tortuosity

Survey of Current Management Practices for Carotid Webs

Endarterectomy for symptomatic internal carotid artery web

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