背景:颈动脉网(CaWeb)是一种罕见的纤维肌性发育不良形式,可产生栓塞性中风。有症状的CaWeb误诊为“隐源性卒中”或“来源不明的栓塞性卒中”是常见的,并可导致复发,灾难性的神经系统事件.文献中关于CaWeb的报道很少,他们的自然历史知之甚少。适当的管理仍然存在争议。
方法:CaWeb被定义为单一,像架子一样,在计算机断层扫描血管造影(CTA)或脑血管造影中,颈动脉后外侧球中的线性投影导致充盈缺损。通过血管神经科医师和血管外科医生的合作评估,确定了在具有高容量卒中中心的单一机构中出现有症状的CaWeb病例。
结果:在6年期间(2016-2022年),确定了52例症状性CaWeb患者。平均年龄为49岁(范围,29-73),35/52(67%)是非裔美国人,18/52(35%)是50岁以下的非洲裔美国女性。患者最初出现卒中(47/52,90%)或TIA(5/52,10%)。根据NASCET标准,狭窄在49/52(94%)中<50%,和0/52(0%)CaWebs被鉴定为颈动脉双工。通过在多个平面中检查的CTA或在外侧投影中检查的脑血管造影来做出明确诊断,以充分评估颈动脉后外侧球。在那里看到52/52(100%)的CaWebs。在我们早期的机构经验中,10/52例(19%)有症状的CaWeb患者最初接受抗血小板和他汀类药物双重治疗或全身抗凝治疗-所有患者均患有同侧复发性卒中,平均间隔时间为43个月(范围1-89)。还有五个人永久赤字。明确的治疗包括27/50(56%)的颈动脉内膜切除术或23/50(46%)的颈动脉支架置入术。两次中风无法恢复,干预被推迟。血管造影时20/50(40%)或颈动脉探查时观察到网状相关血栓。从初始卒中到干预的平均间隔为39天。平均随访38个月,无干预后卒中或死亡率报告.
结论:据我们所知,这是迄今为止报道的最大的症状性CaWeb单机构分析.我们的系列显示颈动脉双工不足以诊断,对有症状的CaWeb进行医疗管理是不可接受的。在我们仅接受药物治疗的早期治疗的所有患者中都发生了复发性中风。此后,我们在有症状的CaWeb病例中采用了积极的介入方法,平均随访38个月,无术后卒中报告.在年轻的隐源性中风患者中,尤其是非洲裔美国女性,详细回顾外侧脑血管造影或多平面,需要精细切割的CTA图像以准确排除或诊断CaWeb并避免复发的神经系统事件。
Carotid web (CaWeb) is a rare form of fibromuscular dysplasia that can produce embolic stroke. Misdiagnosis of symptomatic CaWeb as \"cryptogenic stroke\" or \"embolic stroke of unknown source\" is common and can lead to recurrent, catastrophic neurologic events. Reports of CaWeb in the literature are scarce, and their natural history is poorly understood. Appropriate management remains controversial.
CaWeb was defined as a single, shelf-like, linear projection in the posterolateral carotid bulb causing a filling defect on computed tomography angiography (CTA) or cerebral angiography. Cases of symptomatic CaWeb at a single institution with a high-volume stroke center were identified through collaborative evaluation by vascular neurologists and vascular surgeons.
Fifty-two patients with symptomatic CaWeb were identified during a 6-year period (2016-2022). Average age was 49 years (range, 29-73 years), 35 of 52 (67%) were African American, and 18 of 52 (35%) were African American women under age 50. Patients initially presented with stroke (47/52; 90%) or transient ischemic attack (5/52; 10%). Stenosis was <50% in 49 of 52 patients (94%) based on NASCET criteria, and 0 of 52 (0%) CaWebs were identified with carotid duplex. Definitive diagnosis was made by CTA examined in multiple planes or cerebral angiography examined in a lateral projection to adequately assess the posterolateral carotid bulb, where 52 of 52 (100%) of CaWebs were seen. Early in our institutional experience, 10 of 52 patients (19%) with symptomatic CaWeb were managed initially with dual antiplatelet and statin therapy or systemic anticoagulation; all suffered ipsilateral recurrent stroke at an average interval of 43 months (range, 1-89 months), and five were left with permanent deficits. Definitive treatment included carotid endarterectomy in 27 of 50 (56%) or carotid stenting in 23 of 50 (46%). Two strokes were irrecoverable, and intervention was deferred. Web-associated thrombus was observed in 20 of 50 (40%) on angiography or grossly upon carotid exploration. Average interval from initial stroke to intervention was 39 days. After an average follow-up of 38 months, there was no reported postintervention stroke or mortality.
To our knowledge, this is the largest single-institution analysis of symptomatic CaWeb yet reported. Our series demonstrates that carotid duplex is inadequate for diagnosis, and that medical management is unacceptable for symptomatic CaWeb. Recurrent stroke occurred in all patients managed early in our experience with medical therapy alone. We have since adopted an aggressive interventional approach in cases of symptomatic CaWeb, with no postoperative stroke reported over an average follow-up of 38 months. In younger patients presenting with cryptogenic stroke, especially African American women, detailed review of lateral cerebral angiography or multi-planar, fine-cut CTA images is required to accurately rule out or diagnose CaWeb and avoid recurrent neurologic events.