Comparative analysis of stenting for carotid web and atherosclerotic disease.

INTRODUCTION: Carotid Web (CaW) is an increasingly recognized etiology of ischemic stroke, and has been shown to be amenable to endovascular stenting. The technical complexity of stenting for CaW may be lower than for carotid atherosclerotic disease (CAD). We aimed to assess procedural characteristics of stenting for CaW as compared to CAD. METHODS: We retrospectively analyzed a cohort of consecutive patients at a single comprehensive stroke center from 2014 to 2021, who had undergone elective endovascular stent placement for symptomatic CAD or CaW. RESULTS: In total, 118 patients underwent elective stent placement following ischemic stroke/transient ischemic attack; 88 patients had CAD and 30 patients had CaW. CAD patients were older (63.2 vs 51.2 years, p < 0.001), less likely to be female (28.4% vs 73.3%, p < 0.001), and more likely to have pre-existing vascular risk factors. Procedure time (73.0 vs 57.5 min, p = 0.007), radiation exposure (1482 vs 1125 milliGray, p = 0.03), filter time (24 vs 14 min, p = 0.04), and use of pre-stent (68.2% vs 0%, p < 0.001) and post-stent (34.1% vs 3.3%, p < 0.001) balloon angioplasty were higher in CAD cases. There was no significant difference between groups in the rate of periprocedural complications such as hypotension, use of vasopressors, or bradycardia. Recurrent stroke/TIA was reported in five CAD patients and 0 CaW patients by the end of the follow-up period (8.3% vs 0%, p = 0.12). In-stent restenosis was detected in seven CAD patients and 0 CaW patients (10.1% vs 0%, p = 0.09) at a median follow-up of 4 vs 16 months (p = 0.01), respectively. Periprocedural intracranial hemorrhage was not observed in either group. CONCLUSION: Stenting for CaW was found to be technically simpler than CAD and not to confer increased risk of baroreceptor dysregulation. Intimal hyperplasia was uncommon in CaW cases.

Carotid web: an under-recognized and misdiagnosed ischemic stroke etiology.

BACKGROUND: Carotid web (CaW) constitutes a possible cause of ischemic stroke, particularly large vessel occlusion syndromes. We aim to evaluate misdiagnosis rates and diagnosis trends for CaW. METHODS: Based on CT angiography (CTA), we prospectively identified a cohort of patients with symptomatic CaW treated at two comprehensive stroke centers (CSC) from 2014 to 2020 to assess misdiagnosis. Official CTA reports from the CSCs and referring hospitals were then reviewed for mention of CaW. For diagnosis trends, we retrospectively analyzed a CSC electronic medical record, identifying patients with CaW mentioned in an official CTA report from 2011 to 2020. RESULTS: For misdiagnosis, 56 patients with symptomatic CaW were identified in the CSCs; 16 (28%) had bilateral CaW, totaling 72 CaWs. Only one CaW (5.5%) was reported at referring facilities, from 14 patients/18 CaWs imaged with CTA. Conversely, 43 (69%) CaWs were reported from 49 patients/62 CaWs at the CSC (p<0.01). For diagnosis trends, from 2011 to 2020, 242 patients at a CSC accounted for 266 CTA reports mentioning CaW. The majority of these reports (n=206, 77%) were associated with stroke/transient ischemic attack (TIA) ICD-9/ICD-10 codes. The rate of CaW diagnosis adjusted per 1000 patients with stroke/TIA increased over time, 2015 being the most significant point of change ('joinpoint'; p=0.01). The analysis of CaW mentions normalized per 1000 CTA reports also showed increasing rates of diagnosis over time (joinpoint:2014; p<0.02). CONCLUSION: CaW was predominantly identified in patients with strokes/TIAs rather than asymptomatic patients. CaW was commonly overlooked in facilities with lower levels of cerebrovascular certification. Recognition of CaW at a CSC has significantly increased over time, independent of overall imaging and stroke patient volume.