Two Cases of Symptomatic Carotid Web Treated by Carotid Artery Stenting
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Two Cases of Symptomatic Carotid Web Treated by Carotid Artery Stenting F. Drescher1 · I. Kleffner2 · W. Weber1 · S. Fischer1 Received: 6 February 2020 / Accepted: 20 March 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Introduction Carotid web (CW) is a rare manifestation of focal fibromuscular dysplasia. It has been recognized as causative for stroke especially in young and middle aged patients with incidences varying between 1–37% of all cryptogenic strokes [1–4]. It is defined as an abnormal shelf-like aggregation of intimal fibrous tissue at the carotid bulb. The typical appearance on angiography (computed tomography angiography, CTA or digital subtraction angiography, DSA) is an intraluminal defect of contrast filling affecting the posterolateral wall of the proximal internal carotid artery (ICA) [3]. This article presents two cases of transient ischemic attack (TIA) and ischemic stroke caused by CW that were successfully treated by reconstruction of the ICA using a self-expandable stent.
Case Report A 49-year-old female patient was referred to this hospital after an episode of aphasia. The examination with CTA revealed a shelf-like filling defect emanating from the posterior wall of the left ICA. There was no evidence of cerebral ischemia; however, an additional magnetic resonance imaging (MRI) examination confirmed the diagnosis of a CW with a typical thin posterior septum projecting into the lumen of the left ICA.
S. Fischer
A DSA examination performed to rule out a carotid artery dissection showed a pseudoaneurysmatic bulging of the left internal carotid artery with pooling of contrast up to the venous phase (Fig. 1a, b). The case was discussed in the neurovascular board and 2 days later a double layer stent (Caspar RX Carotid Artery Stent™, 7 × 30, Microvention, Tustin, CA, USA) was placed without predilatation or postdilatation. The patient was kept on dual antiplatelet therapy for 3 months followed by a monotherapy with acetylsalicylic acid (ASA). A follow-up angiography performed 3 months post-intervention demonstrated a correct reconstruction of the ICA. The patient was neurologically independent with a modified Rankin scale (mRS) of 0. No recurrent ischemic events occurred. The second case was a 40-year-old female patient who presented with acute right-sided hemiparesis and aphasia. The CTA showed a severe stenosis of the left proximal ICA without clear evidence of a CW and an occlusion of the left middle cerebral artery. Diagnostic angiography revealed the typical finding of a CW with a focal filling defect at the posterior wall of the vessel. This was treated by implantation of a Carotid WALLSTENT™ (7 × 40 mm) (Boston Scientific, Boston, MA, USA) followed by mild adaptation to the vessel wall with a 5.0 mm balloon (Fig. 2a, b). The maneuver was followed by mechanical thrombectomy. The patient was discharged with a minor persisting neurological deficit (mRS 1). According to standard practice the patient was kept on dual antiplatelet therapy for 3 months foll
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