Yamaguchi Yoshitaka, Miyata Kei, Tomeoka Fumiki, Ajiki Minoru, Takada Tatsuro
Department of Cerebrovascular Medicine, Teine Keijinkai Hospital, Sapporo, JPN.
Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, JPN.
Cureus. 2024 Oct 23;16(10):e72237. doi: 10.7759/cureus.72237. eCollection 2024 Oct.
Carotid web, a form of fibromuscular dysplasia, involves a thin, membrane-like tissue in the carotid bulb that can cause thrombus formation and is linked to cryptogenic ischemic stroke. Diagnosis typically relies on detecting a shelf-like filling defect in digital subtraction angiography or 3D-CT angiography. We report a case of the symptomatic carotid web that could not be diagnosed using DSA or 3D-CT angiography due to a lodged thrombus but was successfully identified through carotid ultrasonography. A 44-year-old woman with a history of subarachnoid hemorrhage developed left hemiparesis and was diagnosed with acute cerebral infarction due to right middle cerebral artery occlusion. Mechanical thrombectomy achieved partial reperfusion. DSA and postoperative 3D-CT angiography showed only mild stenosis at the posterior wall of the carotid bulb. However, carotid ultrasonography revealed a membrane-like structure with a lodged thrombus, leading to a diagnosis of a carotid web. Carotid artery stenting was performed to prevent further cerebral embolism, and the postoperative course was uneventful. While digital subtraction angiography and 3D-CT angiography are regarded as the gold standards for diagnosing carotid web, they may only reveal a slight, insignificant filling defect, potentially leading to a missed diagnosis when a large thrombus is present. Carotid ultrasonography is particularly useful in such cases. As revascularization procedures with CEA or CAS are highly effective in lowering the risk of recurrent ischemic stroke in symptomatic CaW, it is crucial to avoid missed diagnoses of symptomatic CaW in ESUS cases, particularly in patients without typical vascular risk factors, through multimodal imaging, including carotid ultrasonography, and to consider revascularization to prevent further stroke recurrence.
颈动脉纤维膜，作为纤维肌发育不良的一种形式，是指在颈动脉窦内存在的一种薄的、膜状组织，可导致血栓形成，并与不明原因的缺血性卒中相关。诊断通常依靠在数字减影血管造影或三维CT血管造影中检测到类似搁板样的充盈缺损。我们报告一例有症状的颈动脉纤维膜病例，由于血栓形成，数字减影血管造影或三维CT血管造影均未能诊断出该病例，但通过颈动脉超声检查成功确诊。一名有蛛网膜下腔出血病史的44岁女性出现左侧偏瘫，诊断为右侧大脑中动脉闭塞所致急性脑梗死。机械取栓实现了部分再灌注。数字减影血管造影和术后三维CT血管造影仅显示颈动脉窦后壁轻度狭窄。然而，颈动脉超声检查发现了一个伴有血栓形成的膜状结构，从而诊断为颈动脉纤维膜。为预防进一步的脑栓塞，实施了颈动脉支架置入术，术后病程平稳。虽然数字减影血管造影和三维CT血管造影被视为诊断颈动脉纤维膜的金标准，但它们可能仅显示轻微的、不显著的充盈缺损，当存在大血栓时可能导致漏诊。在这种情况下，颈动脉超声检查特别有用。由于颈动脉内膜切除术（CEA）或颈动脉血管成形术及支架置入术（CAS）等血运重建手术在降低有症状的颈动脉纤维膜患者复发性缺血性卒中风险方面非常有效，因此，对于不明原因的卒中（ESUS）病例，尤其是没有典型血管危险因素的患者，通过包括颈动脉超声检查在内的多模态成像避免漏诊有症状的颈动脉纤维膜，并考虑进行血运重建以预防进一步的卒中复发至关重要。
