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Título

CAROTID WEB: A SUBDIAGNOSED ISCHEMIC STROKE CAUSE IN YOUNG ADULTS

RESUMO

CASE: 40-year old male was admitted in the emergency room with a sudden onset left hemiparesis and asymmetry of the smile 2.5 hours ago. Previously hypertensive, alcoholic and ex-smoker. The primary neurologic examination showed a right middle cerebral artery (RMCA) syndrome with a NIHSS (National Institutes of Health Stroke Scale) of 14. A cranial computerized tomography (CT) showed a hyperdensity of the RMCA and an ASPECTS of 10. Intravenous thrombolytic therapy with Alteplase 0.9mg/kg was administered, since no contraindications were found, with a subsequent NIHSS of 11. Laboratory investigation, electrocardiogram and transthoracic echocardiogram showed no relevant findings. An arterial angiotomography (AT) of the cervical vessels found a minor irregularity with a linear aspect in the posterior wall of the right carotid bulb, suggesting a carotid membrane, which was confirmed with an angiography. An angioplasty with stent of the right internal carotid artery was opted as treatment.
DISCUSSION: The carotid web is a cause of Ischemic Stroke in young adults with no cardiovascular history and no positive investigation for other cerebrovascular diseases. It is shown as a projection of linear aspect inside the bulbar portion of the carotid artery, and is better visualized in the sagittal cuts of the CT. It is an acquired vasculopathy, pathologically defined as an intimate fibromuscular dysplasia. The ischemic stroke pathogeny resides in the stagnation of flow and remote embolization of fibrin-based clots. It can cause recurrent hemispheric ischemic strokes. Although easily seen in ATs, the carotid web can be missed or misinterpreted, as it doesn’t cause a significant hemodynamic stenosis and can mimic an arterial dissection, non-calcified arteriosclerotic plaque or an intraluminal thrombus. The diagnostic golden standard is the angiography, with a non-invasive option being the AT of the neck. Treatment options include antiplatelet and anticoagulant therapies, both with a high recurrency rate (40-50%). Both carotid endarterectomy and angioplasty with stent in the internal carotid are definitive treatments.
FINAL CONSIDERATIONS: The therapeutic decision making in the secondary prevention of the ischemic stroke depends on the cause of said stroke, being the vascular study a primary one in the diagnostic investigation. The carotid web is an undiagnosed and sub treated entity, making it an important point of discussion among neurological cases.

Palavras Chave

Carotid web, Ischemic stroke, Cerebrovascular disease

Área

Doença Cerebrovascular