Carotid Web Recurrent Emboli — The Imperfect Storm

A super instructive case by Alex Solich MD, Ph.D.  Neurointerventional Program, Örebro University, Sweden

Lest anyone think carotid webs are a minor nuisance with an occasional small embolus, unimportant in the big scheme of stroke risk factors — no, no, no, no!

Young patient with left MCA syndrome

Aspiration 8 min groin to TICI 3 — organized white thrombus

A bit of hemorrhage in the inferior parietal sulcus. TEE – medium PFO.  Several 40-60 sec runs of afib on telemetry

However, 2.5 days later…

Another TICI 3 — organized white thrombus

After 33 hours — guess what?

Carotid T

TICI 2C — the good distal angular kind.  Thrombus well organized, required triever + aspiration

All hypercoagulable workup is negative

Next day — 4th time… 

TICI 3 of another T

The culprit is a Carotid Web — see how terrible they can be — and an important cause of emboli and stroke — including recurrent big ones — in the young and healthy.

Right CCA

Angio — the more contrast stasis behind the web, the worse they are

Antiplatelets don’t work well for the big ones — the problem is stasis — so its either anticoagulation or carotid artery stent / endarterectomy

Post stent

See Carotid Web page as well — but this is the best case to show how important they are