Background Carotid web (CaW) is a shelf-like linear filling defect in the posterior aspect of the internal carotid bulb, representing an intimal variant of fibromuscular dysplasia. The diagnosis of CaW is traditionally restricted to digital subtraction angiography (DSA), CT/MR angiography (CTA/MRA), and Duplex ultrasonography. In this series of patients with acute ischemic stroke, we evaluated the potential utility of intravascular ultrasound (IVUS) in further characterizing suspected CaWs.
Methods This is a case series of three patients with suspected CaW who underwent DSA for treatment or investigation of large vessel occlusion strokes. In all cases the stroke investigation failed to identify an alternative cause, and the stroke etiology was attributed to a symptomatic CaW. The procedure consisted of positioning a guide catheter in the common carotid artery, navigating the IVUS probe distal to the carotid bulb, and then retracting the probe with a manual pullback. The acquired images were then reviewed in an independent workstation
Results In two of the three cases, IVUS showed an isoechoic-to-hyperechoic focal eccentric area at the posterior carotid bulb, consistent with CaW. The endoluminal protrusion was inconspicuous on IVUS due to the low resolution of ultrasound not allowing a clear differentiation between fibrosis, thrombosis, and atherosclerosis. No abnormalities commonly associated with atherosclerotic disease or dissections were noted. The CaW could not be depicted in the third patient.
Conclusion The use of IVUS in the diagnosis of CaW may have limited relevance. Continued investigation of other imaging modalities for accurate CaW diagnosis is recommended.
- vessel wall
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Contributors SH: acquisition of data, drafting of the manuscript. RN: interpretation of data, critical revision of manuscript. ARA, RS, MM: data acquisition, critical revision of manuscript. DCH: study conception, design of the work, acquisition of data. All authors gave final approval of the version to be published, and are in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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 SH, ARA, RS, MM: none. DCH: Consultant for Stryker and Vesalio, Viz-AI (stock options). RN: Principal Investigator, Stryker Neurovascular (DAWN trial (no compensation), Trevo‑2 trial), Cerenovus/Neuravi (ENDOLOW trial, no compensation); consultant to Stryker Neurovascular; steering committee member, Stryker Neurovascular (no compensation), Medtronic (SWIFT trial, SWIFT Prime trial, no compensation), Cerenovus/Neuravi (ARISE‑2 trial, no compensation); angiographic core lab, Medtronic (STAR trial); executive committee member, Penumbra (no compensation); Physician advisory board, Cerenovus/Neuravi, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Allm Inc (no compensation), Viz-AI; stock options.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.