Vascular Imaging Follow-Up in Carotid Webs: Is There Vascular Remodeling?

HomeStroke: Vascular and Interventional NeurologyAhead of PrintVascular Imaging Follow‐Up in Carotid Webs: Is There Vascular Remodeling? Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessLetterPDF/EPUBVascular Imaging Follow‐Up in Carotid Webs: Is There Vascular Remodeling? Sitara Koneru, MD, Raul G. Nogueira, MD, David Landzberg, MD, Ehizele Osehobo, MD, Qasem AlShaer, MD, Alhamza Al‐Bayati, MD, Fadi Nahab, MD and Diogo C. Haussen, MD Sitara KoneruSitara Koneru , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, Search for more papers by this author , Raul G. NogueiraRaul G. Nogueira , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, Search for more papers by this author , David LandzbergDavid Landzberg , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, Search for more papers by this author , Ehizele OsehoboEhizele Osehobo , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, Search for more papers by this author , Qasem AlShaerQasem AlShaer , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, Search for more papers by this author , Alhamza Al‐BayatiAlhamza Al‐Bayati , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, Search for more papers by this author , Fadi NahabFadi Nahab , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, Search for more papers by this author and Diogo C. HaussenDiogo C. Haussen *Correspondence to: Diogo C. Haussen, MD, Emory University Hospital/Grady Memorial Hospital, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0003-1884-2196 , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, Search for more papers by this author Originally published21 Oct 2022https://doi.org/10.1161/SVIN.122.000559Stroke: Vascular and Interventional Neurology. 2022;0:e000559Carotid web (CaW) is a shelf‐like fibrotic projection at the carotid bulb and constitutes an underrecognized cause of ischemic stroke. The histological natural history of these lesions has not been investigated. Conversely, carotid atherosclerotic lesions have been extensively documented to undergo dynamic processes at the cellular and molecular levels, leading to both positive and negative remodeling.1 Considering that 3‐dimensional volumetric measurements on computed tomography angiography (CTA) for CaW size quantification have been demonstrated to be highly reproducible,2 we aimed to evaluate if CaW is a static or dynamic entity on delayed vascular imaging based on lesion volume.This was a retrospective analysis of patients diagnosed with CaW between September 2014 and June 2021 at our comprehensive stroke center. Patients who had at least 2 good‐quality CTAs that were at least 6 months apart were included (cases with superimposed thrombus were excluded). CaWs were quantified with 3‐dimensional measurements using Horos software (New York, NY) via volumetric analysis of freehand‐delineated CaW borders on thin cuts of axial CTA (Figure 1A). North American symptomatic carotid endarterectomy trial criteria were used to evaluate the degree of stenosis.3Download figureDownload PowerPointFigure 1. Measurement methodology and temporal trends in lesion volume. A, Representative sections of 3‐dimensional volumetric measurement. B, Volumetric measurements for all lesions on initial and follow‐up computed tomography angiography. CaW indicates carotid web.A total of 20 CaW lesions in 17 patients were included. The median imaging follow‐up window was 16 months (interquartile range [IQR], 12–21 months; range, 6–58 months). Median patient age was 44 years, 75% were women, 30% had hypertension, 30% had hyperlipidemia, 20% had diabetes, 0% had atrial fibrillation, and 10% were active smokers. Of the included CaWs, 75% were symptomatic, whereas 25% were asymptomatic.Median volume of CaW on initial CTA (8.27 mm3; IQR; 4.5–11.6 mm3; range, 2.2–30.4 mm3) was comparable with the median volume of CaW on the most recent CTA (8.44 mm3; IQR, 4.5–11.6 mm3; range, 2.3–29.4 mm3; P<0.001; Figure 1B). The CaW volumetric measurement correlation between the initial and most recent CTA was near perfect (rs=−0.99; P<0.001). The median change in measured volume of CaW between the first and last CTA was −0.03 mm3 (IQR, −0.6 to 0.4 mm3; range, −1 to 0.8 mm3). Median degree of stenosis was 8.1% (IQR, 4.5%–17.1%; range, 0.4%–31.2%).The duration of follow‐up imaging was not correlated with change in CaW volume (Kendall τb=0.06; P=0.72). The initial CaW volume was not found to be correlated to the degree of stenosis (τb=−0.04; P=0.80).In atherosclerotic disease, the progression of carotid total plaque area has been shown to be a strong predictor of clinical outcomes.4, 5 In a large cohort of patients followed annually with carotid total plaque measurements, about 63% had progression (defined as an increase by 5 mm2 from baseline), 28% had regression (decrease by 5 mm2), and 16% had no change.4 The natural history of fibromuscular dysplasia lesions is not well established. The median change in CaW volume in our cohort of patients was −0.03 mm3, suggesting a stable condition. Although there are limitations to this study, including the small number of patients with relatively short lengths of follow‐up, we showed that webs appear to be a relatively static lesion. Considering that favorable remodeling was not observed, long‐term medical therapy may have to be considered for protection.Nonstandard Abbreviations and AcronymsCaWcarotid webCTAcomputed tomography angiographyAcknowledgmentsS.K. was involved in the conception and design of the study, acquisition and analysis of data, and drafted a significant proportion of the article and figures. R.G.N. was involved with the conception and design of the study and revised the article for intellectual content. D.L. was involved with acquisition and analysis of data and revised the article for intellectual content. E.O. was involved with acquisition and analysis of data and revised the article for intellectual content. Q.A. was involved with acquisition and analysis of data and revised the article for intellectual content. A.A.B was involved in the conception and design of the study and revised the article for intellectual content. F.N. was involved in the conception and design of the study and revised the article for intellectual content. D.C.H. was involved in the conception and design of the study and revised the article for intellectual content.Footnotes*Correspondence to: Diogo C. Haussen, MD, Emory University Hospital/Grady Memorial Hospital, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303. E‐mail: diogo.[email protected]eduThis work was presented at the Society of Vascular and Interventional Neurology Annual Meeting, November 16‐19, 2021.REFERENCES1 Peeters W, Hellings WE, de Kleijn DP, de Vries JP, Moll FL, Vink A, Pasterkamp G. Carotid atherosclerotic plaques stabilize after stroke: insights into the natural process of atherosclerotic plaque stabilization. Arterioscler Thromb Vasc Biol. 2009; 29:128‐133.LinkGoogle Scholar2 Perry da Camara C, Nogueira RG, Al‐Bayati AR, Pisani L, Mohammaden M, Allen JW, Nahab F, Olive Gadea M, Frankel MR, Haussen DC. Comparative analysis between 1‐D, 2‐D and 3‐D carotid web quantification. J Neurointerv Surg. 2022;neurintsurg‐2021‐018192.Google Scholar3 North American Symptomatic Carotid Endarterectomy Trial Collaborators , Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, Ferguson GG, Fox AJ, Rankin RN, Hachinski VC, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high‐grade carotid stenosis. N Engl J Med. 1991; 325:445‐453.CrossrefMedlineGoogle Scholar4 Spence JD, Eliasziw M, DiCicco M, Hackam DG, Galil R, Lohmann T. Carotid plaque area: a tool for targeting and evaluating vascular preventive therapy. Stroke. 2002; 33:2916‐2922.LinkGoogle Scholar5 Spence JD, Hackam DG. Treating arteries instead of risk factors: a paradigm change in management of atherosclerosis. Stroke. 2010; 41:1193‐1199.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails Article InformationMetrics © 2022 The Authors. Published on behalf of the American Heart Association, Inc., and the Society of Vascular and Interventional Neurology by Wiley Periodicals LLC.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/SVIN.122.000559 Manuscript receivedJune 22, 2022Manuscript acceptedAugust 29, 2022Originally publishedOctober 21, 2022 PDF download