頸動脈プラークに伴い内腔に浮遊する血栓様塊の検討

A carotid web (CaW) is a non-atheromatous, shelf-like intraluminal projection, commonly affecting the internal carotid artery. It can be associated with embolic stroke, particularly in younger patients without traditional stroke risk factors. The natural history of CaW is not well-established. Several studies have reported on outcomes after interventional and medical therapy with variable results. To synthesize the literature and report the clinical characteristics and management outcomes of patients with CaWs. A systematic literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. 33 studies comprising 737 patients (mean age 50.2 years, female 59.4%, African American 65%) with 835 CaWs were included. The majority of the CaWs were symptomatic (72.9%) with a mean National Institutes of Health Stroke Scale (NIHSS) admission score of 7.5. Atherosclerotic plaques and intramural thrombi were each present in 33% of patients. The classic atherosclerotic and stroke risk factors were prevalent as follows: hypertension 37.8%, diabetes 14.6%, smoking 21.7%, dyslipidemia 16.7%. In total, treatment outcomes were available for 376 patients with 448 symptomatic CaWs (227 medical, 221 interventional). Medical therapy consisted of antiplatelet or anticoagulation medications, while interventional treatment included carotid artery stenting (CAS), carotid endarterectomy (CEA), and internal carotid artery resection and primary anastomosis (ICRA). The interventional group was associated with a significantly lower risk of recurrent ischemic events compared with the medical group (interventional 0%, medical 36.1%; OR 14.18, 95% CI 3.17 to 63.46, P=0.001) over a mean follow-up of 21.2 months. The odds ratio of cerebral ischemic event recurrence was correlated with the need for thrombectomy at the first event and history of dyslipidemia. Most CaWs were found during stroke work-up. Prevention of secondary ischemic events was superior in the interventional management group (CAS, CEA, ICRA) compared with the medical management group.

The carotid web (CW) is an underrecognized source of cryptogenic, embolic stroke in patients younger than 55 years of age, with up to 37% of these patients found to have CW on angiography. Currently, there are little data detailing the best treatment practices to reduce the risk of recurrent stroke in these patients. The authors describe their institutional surgical experience with patients treated via carotid endarterectomy (CEA) for a symptomatic internal carotid artery web. A retrospective, observational cohort study was performed including all patients presenting to the authors' institution with CW. All patients who were screened underwent either carotid artery stenting (CAS) or CEA after presentation with ischemic stroke from January 2019 to February 2020. From this sample, patients with suggestive radiological features and pathologically confirmed CW who underwent CEA were identified. Patient demographics, medical histories, radiological images, surgical results, and clinical outcomes were collected and described using descriptive statistics. A total of 45 patients with symptomatic carotid lesions were treated at the authors' institution during the time period. Twenty patients underwent CAS, 1 of them for a CW. Twenty-five patients were treated via CEA, and of these, 6 presented with ischemic strokes ipsilateral to CWs, including 3 patients who presented with recurrent strokes. The mean patient age was 55 ± 12.6 years and 5 of 6 were women. CT angiography or digital subtraction angiography demonstrated the presence of CWs ipsilateral to the stroke in all patients. All patients underwent resection of CWs using CEA. There were no permanent procedural complications and no patients had stroke recurrence following intervention at the latest follow-up (mean 6.1 ± 4 months). One patient developed mild tongue deviation most likely related to retraction, with complete recovery at follow-up. CEA is a safe and feasible treatment for symptomatic carotid webs and should be considered a viable alternative to CAS in this patient population.

Introduction/Purpose Carotid webs are an underrecognized cause of embolic ischemic stroke, typically presenting in younger patients and often identified by their characteristic shelf‐like morphology and minimal associated stenosis on angiography. However, non‐calcified atherosclerotic plaques can mimic this appearance, leading to diagnostic uncertainty. We report a case of presumed carotid web based on classic imaging features that was found to be an atherosclerotic plaque on histopathologic examination after carotid endarterectomy (CEA). Materials/Methods Single‐patient case report. Results A 58‐year‐old man with hypertension, hyperlipidemia, type II diabetes, and a 10‐pack‐year smoking history presented with acute left hemiparesis, hemispatial neglect, and dysarthria. Last known normal was eight hours before arrival; NIH Stroke Scale score was 18. Non‐contrast head CT demonstrated right M1 segment hyperdensity, mild right insular region hypodensity, and no acute hemorrhage. CT angiography revealed right M1 occlusion. The patient underwent mechanical thrombectomy with complete reperfusion (TICI 3). Digital subtraction angiography (DSA) confirmed a proximal right M1 occlusion and revealed an intraluminal, shelf‐like filling defect arising from the posterior wall of the right internal carotid artery (ICA) at the level of the carotid bulb, with contrast stasis posterior to the lesion, suspicious for carotid web. In retrospect, the abnormality was also visible on initial CTA, with only 30% luminal stenosis by NASCET criteria.Brain MRI demonstrated infarcts in the right MCA territory, specifically involving the right insula, basal ganglia, and frontal and parietal lobes, with no chronic infarcts in other vascular territories. Routine coagulation panels were normal, LDL was 60 mg/dL, HbA1c was 11.0%, transthoracic echocardiography was unremarkable, and non‐invasive ambulatory cardiac monitor detected no episodes of atrial fibrillation or atrial tachycardia within two weeks of recording. CT of the chest was negative for malignancy. Given the patient's relatively young age, the presence of an embolic‐appearing ischemic stroke without an obvious cardioembolic source or underlying hypercoagulable state, and the classic shelf‐like morphology with minimal stenosis, artery‐to‐artery embolization from carotid web was considered the most likely stroke etiology. The patient was discharged to acute inpatient rehabilitation. One month later, he underwent elective right CEA for secondary stroke prevention. Intraoperatively, the suspected web was visualized and resected en bloc. Histopathological analysis revealed the lesion to be a non‐calcified atherosclerotic plaque rather than a fibrous intimal web.Following this unexpected diagnosis, the patient's medical management was adjusted to emphasize aggressive atherosclerosis risk reduction. At one‐year follow‐up, the patient remained neurologically intact with no recurrent cerebrovascular events. He was adherent to prescribed medications with improved glycemic control and LDL cholesterol < 70 mg/dL. Conclusion This case illustrates that even lesions with classic radiographic features of carotid webs may represent non‐calcified atherosclerotic plaques, particularly in patients with vascular risk factors. As imaging alone may be insufficient for definitive diagnosis, CEA not only restores ICA patency but also provides diagnostic tissue, enabling accurate etiologic classification and appropriate long‐term secondary stroke prevention. In cases of embolic stroke with equivocal imaging findings, particularly when the clinical context raises concern for both carotid web and atherosclerosis, histopathologic confirmation can be essential.

Background: Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are two alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. It has been noted that substantial differences in clinical characteristics between patients referred for CAS vs. CEA may preclude direct comparisons of effectiveness. We sought to rigorously examine the clinical profiles of patients referred for CAS vs. CEA. Methods: We assessed clinical characteristics of 12,701 patients referred for CAS or CEA from the NCDR-CARE multi-center prospective registry. We compared 44 clinical and demographic variables, and used these to create a propensity score for referral for CAS. To explore the comparability of CAS and CES patients, we stratified the cohort into quintiles of propensity score to determine the degree of overlap between CAS and CEA patients. Results: Among the 8,069 patients referred for CAS and 4,632 patients referred for CEA, the CAS patients were much more likely to have significant comorbidities. (Figure) While the propensity model balanced most covariates, the pooled standardized differences remained >10% for: CAD, MI within 6 weeks, prior seizure, and CAS and CEA restenosis, all of which were more common in the CAS group. After propensity matching and stratification by quintile, CEA patients comprised 70% of the lowest quintile but only 6% of the uppermost quintile. Conclusion: Clinical characteristics of patients referred for CAS differ markedly from those referred for CEA. Due to the clinical disparities between these patient groups, comparative analyses performed to date outside of prospective randomized controlled trials may be invalid.

Influence of multiple stents on periprocedural stroke after carotid artery stenting in the Carotid Revascularization Endarterectomy versus Stent Trial (CREST)

Embolic stroke is an infrequent complication of carotid endarterectomy. Somatosensory evoked potential monitoring detected delayed acute neurological deterioration during endarterectomy performed on a 71-year-old woman. Intraoperative arteriography performed via an indwelling shunt revealed thrombus within the middle cerebral artery and distal branches. A microcatheter was placed into the internal carotid artery via the arteriotomy and advanced into the middle cerebral artery. Urokinase was infused into and around the thrombus until almost complete thrombolysis had been achieved. The patient recovered quickly and was discharged without neurological deficit.

Background: Over 9 million dual-eligible beneficiaries rely on both Medicare and Medicaid to obtain critical medical services. Medicaid serves as a safety net for low-income Medicare beneficiaries with limited assets; however, it is unknown whether dual-eligible patients have comparable outcomes for procedures to non-dual-eligible Medicare beneficiaries. We compared outcomes by dual-eligible status for patients undergoing carotid endarterectomy (CEA). Methods: We identified Medicare fee-for-service beneficiaries aged ≥65y who underwent CEA (ICD-9 38.12) from 2003-2010. Beneficiaries with ≥1m of Medicaid coverage were considered dual eligible. We fit mixed models with a random intercept for state and adjustment for demographics, comorbidities, and symptomatic status to assess the relationship between dual-eligible status and outcomes. Results: A total of 35,832 dual-eligible and 470,134 non-dual-eligible beneficiaries were hospitalized for CEA during the study period. The percentage of dual-eligible CEA patients decreased from 7.9% in 2003 to 6.7% in 2010. Dual eligibles were more likely to be younger, female, of nonwhite race, and living with comorbid conditions (e.g., heart failure, renal failure, diabetes) and symptomatic carotid disease. Dual eligibles had higher 30d composite outcomes including stroke (Table), but the associations with 1y stroke became nonsignificant from 2003-2010. Dual-eligible status was associated with higher 30d and 1y mortality after CEA throughout the study period. Conclusions: Dual-eligible Medicare-Medicaid beneficiaries had worse short-term stroke and mortality outcomes than other beneficiaries, even after adjustment for comorbidities. Our results indicate a need to understand factors contributing to poorer outcomes. Challenges include the split accountability between the two programs and the diverse sociodemographics, clinical characteristics, and generally poorer health of the patients.

Carotid artery stenting (CAS) has been widely accepted as a valuable therapeutic alternative to carotid endarterectomy (CEA) for high-grade carotid stenosis. Because carotid revascularization including CAS is usually performed in patients with minimal or no neurological deficits, utmost care should be taken to avoid periprocedural complications. The major concerns associated with CAS are embolic stroke, hyperperfusion syndrome (HPS), and perioperative myocardial infarction.Plaque characteristics, cerebral blood flow (CBF) in the affected cerebral hemisphere, and concomitant coronary artery disease prior to CAS are all important to assess the risks of these complications and are routinely evaluated.Tailored CAS is planned based on findings of preoperative evaluation, as follows. (1) If the plaque component is thought vulnerable, proximal embolic protection methods, use of a closed-cell-type stent, or referral to CEA should be considered to avoid embolic complications. (2) If patients have severe CBF impairment, staged angioplasty is an effective strategy to prevent postoperative HPS. (3) If concomitant cardiac diseases are present, the optimal treatment sequence should be discussed between cardiologists and neurointerventionalists.These tailored strategies based on preoperative risk evaluations may lead to safer procedures and better clinical outcome in CAS patients.

Prospective randomized study of carotid endarterectomy with polytetrafluoroethylene versus collagen-impregnated Dacron (Hemashield) patching: Perioperative (30-day) results

Intracranial hemorrhage (ICH) is a rare and devastating complication of carotid revascularization. We sought to determine the prevalence of, type of, and risk factors associated with ICH among recipients of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) within the National Inpatient Sample (NIS). Postoperative cases of ICH after CEA (International Classification of Disease 9th edition [ICD-9]: 38.12) or CAS (ICD-9: 00.63) were retrieved from the 2001 to 2008 NIS. Clinical presentation (asymptomatic versus symptomatic), discharge status, in-hospital mortality, demographics, and hospital characteristics were extracted from NIS data. Charlson indices of comorbidity were determined based on ICD-9 and clinical classification software codes. Multivariate regression was used to determine the impact of revascularization procedure type and symptom status on adverse outcomes, including ICH, in-hospital mortality, and unfavorable discharge status. Among 57,663,486 NIS hospital admissions, 215,012 CEA and 13,884 CAS procedures were performed. Symptomatic presentations represented the minority of CEA (N=10,049; 5%) and CAS cases (N=1251; 10%). ICH occurred significantly more frequently after CAS than CEA in both symptomatic (4.4% versus 0.8%; P<0.0001) and asymptomatic presentations (0.5% versus 0.06%; P<0.0001). Multivariate regression suggested that symptomatic presentations (versus asymptomatic) and CAS procedures (versus CEA) were both independently predictive of 6-fold to 7-fold increases in the frequency of postoperative ICH. ICH was independently predictive in a 30-fold increased risk of mortality before discharge. CAS procedures are associated with elevated adverse outcomes, including ICH, in-hospital death, and unfavorable discharges, especially among symptomatic presentations.

Atherosclerotic Plaque Composition and Occurrence of Restenosis After Carotid Endarterectomy

Clinical Characteristics and Outcomes in Carotid Endarterectomy for Internal Carotid Artery Stenosis in a Japanese Population: 10-Year Microsurgical Experience

Long-term durability and clinical outcome of a prospective randomized trial comparing carotid endarterectomy with ACUSEAL polytetrafluoroethylene patching versus pericardial patching

A diagnosis based on the presumed mechanism of stroke onset is useful for management strategies in acute ischemic stroke. Ninety-two patients with embolic (cardiac or artery-to-artery) and 107 with non-embolic (thrombotic or hemodynamic) stroke were diagnosed on strict cerebral angiographic criteria alone. To clearly discriminate between these two groups, the neurological and computed tomographic (CT) findings were then compared. Rapidity of onset, vomiting, urinary incontinence, level of consciousness, cervical bruit, anisocoria, tongue deviation, sensory disturbance, and CT findings (location of hypodense area, findings of brain edema and hemorrhagic transformation) were discriminatory factors between the two groups (p<0.01). According to these 11 items, we prepared a numerical table for quantitative differential diagnosis. A diagnostic accuracy of 98.9% for embolic and 87.9% for non-embolic stroke in internal verification, and 90.0% and 82.9%, respectively, in external verification was observed. The differences in clinical features and CT findings between embolic and non-embolic stroke may reflect the pathophysiological mechanisms of the occlusive process of cerebral artery as well as the extent and severity of ischemia.

Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery