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Review
Carotid web: an occult mechanism of embolic stroke
  1. Brian Mac Grory1,
  2. Bart J Emmer2,
  3. Stefan D Roosendaal2,
  4. David Zagzag3,
  5. Shadi Yaghi4,
  6. Erez Nossek5
  1. 1 Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
  2. 2 Department of Radiology, Amsterdam University Medical Centres, Duivendrecht, Noord-Holland, The Netherlands
  3. 3 Department of Pathology, NYU Langone Health, New York, New York, USA
  4. 4 Department of Neurology, NYU Langone Medical Center, New York, New York, USA
  5. 5 Department of Neurosurgery, New York University School of Medicine, New York, New York, USA
  1. Correspondence to Dr Brian Mac Grory, Neurology, Duke University School of Medicine, Durham, NC 27710, USA; brianmacgrory{at}yahoo.ie

Abstract

The carotid web is a proposed stroke mechanism that may underlie cryptogenic stroke, particularly in younger patients without vascular risk factors. The web appears as a shelf-like projection into the lumen of the proximal cervical internal carotid artery without evidence of calcification. It is pathologically defined as intimal fibromuscular dysplasia. Altered haemodynamics distal to the web cause flow stagnation and remote embolisation of fibrin-based clots. It is best demonstrated and diagnosed on CT angiography (CTA) of the neck because of its ability to resolve calcium and create multiplanar reconstructions. Although they can be readily visualised on CTA, carotid webs may be missed or misinterpreted because they do not typically cause haemodynamically significant stenosis and can mimic arterial dissection, non-calcified atherosclerotic plaque and intraluminal thrombus. Options for management include antiplatelet therapy, carotid endarterectomy and carotid artery stenting. Modern management strategies for cryptogenic stroke include long-term cardiac monitoring, further investigation for structural cardiac disease and a diagnostic workup for arterial hypercoagulability, however, these strategies are not likely to capture the possibility of a carotid web. Carotid webs should be suspected in a young patient presenting with recurrent unihemispheric strokes particularly when conventional vascular risk factors are not present.

  • stroke
  • cerebrovascular disease
  • vascular surgery
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Footnotes

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  • Contributors BMG conceived the research, drafted the manuscript, prepared radiology images and critically revised the manuscript. BJE prepared radiology images and critically revised the manuscript. SDR prepared radiology images and critically revised the manuscript. DZ interpreted pathological specimens, prepared pathological slides and critically revised the manuscript. SY critically revised the manuscript. EN conceived the research, obtained intraoperative imaging and critically revised the manuscript. There are no other relevant contributions. All authors have reviewed the final paper and given their approval for submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

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