Case Report

Transient Ischemic Attack and Carotid Web with Atherosclerotic Plaque

by Ourtani Anissa1*, Tota Vito1, Al-Saad Wisam2, Moorthamers Sofie3, Duttmann Ruth4, Barchiche Reda5, Sanoussi Said2, Gazagnes MarieDominique1

1Department of Neurology, University Hospital CHU Brugmann, Brussels, Belgium

2Department of Radiology, University Hospital CHU Brugmann, Brussels, Belgium

3Department of Emergency Medicine, University Hospital CHU Brugmann, Brussels, Belgium

4Department of Anatomical Pathology, University Hospital CHU Brugmann, Brussels, Belgium

5Department of Vascular Surgery, University Hospital CHU Brugmann, Brussels, Belgium

*Corresponding author: Ourtani Anissa, Department of Neurology, University Hospital CHU Brugmann, Brussels, Belgium

Received Date: 21 October 2023

Accepted Date: 25 October 2023

Published Date: 27 October 2023

Citation:  Ourtani A, Vito T, Wisam A, Sofie M, Ruth D, et al (2023) Transient Ischemic Attack and Carotid Web with Atherosclerotic Plaque. Ann Case Report. 8: 1490. DOI: https://doi.org/10.29011/2574-7754.101490

Abstract

Carotid web, considered a non-atherosclerotic disease, has been increasingly identified as a risk factor for ischemic stroke and transient ischemic attack. The association of an atherosclerotic plaque with carotid web is very rarely described, especially in the absence of atherosclerotic risk factors. Here, we report a case of a 23-year-old woman presenting symptoms of transient ischemic attack, with ipsilateral carotid web associated to an atherosclerotic plaque with signs of intraplaque haemorrhage, successfully treated with carotid endarterectomy.

Keywords: Transient Ischemic Attack; Atherosclerotic Plaque; Carotid Web; Young.

Introduction

Carotid web (CaW) is a rare and underdiagnosed cause of ischemic stroke, more frequently found in young females [1] and in patients of African descent [2], with absence of vascular risk factors in the majority of patients [3]. It is defined on angiography as an intraluminal-filling defect mostly located in the posterior wall of the carotid bulb [4]. Histologically it is thought to be an intimal variant of fibromuscular dysplasia with intimal fibrosis and hyperplasia [1,3,4]. We report a case of a young woman presenting symptoms of transient ischemic attack (TIA) in the left middle cerebral artery territory, in which computed tomography angiography (CTA) of head and neck revealed an ipsilateral CaW. Brain magnetic resonance imaging (MRI) with T1 weighted fat-saturated (T1FS) sequence of the cervical vessels detected an atherosclerotic plaque with signs of intraplaque haemorrhage associated to the CaW. The patient was subsequently treated with carotid endarterectomy and follow-up at four months showed no recurrent neurological symptoms.

Case Presentation

A 23-year-old woman of African descent, with no relevant medical history, presented at the emergency department after experiencing a transient right brachiofacial hypoesthesia lasting for approximately 5 minutes. Neurological examination at admission was normal. There were no prodromal symptoms, trauma or headache associated. The diagnosis of TIA was made and the patient was included in our TIA clinic. Her home medication consisted solely of a combined oral contraceptive pill. No other vascular risk factors were identified and family history was unremarkable. CTA of head and neck showed a shelflike protrusion in the posterior wall of the left carotid artery bulb consistent with CaW (Figure 1). The right carotid artery showed no anomalies and in particular, no contralateral CaW was identified. Brain MRI revealed no recent ischemic lesion on diffusion weighted imaging (DWI). T1FS imaging of the cervical vessels showed the presence of a non-stenotic atherosclerotic plaque with signs of intraplaque haemorrhage along the posterior wall of the left carotid artery bulb associated to the CaW (Figure 2). Dual antiplatelet therapy (Aspirin and Clopidogrel) was initiated together with a statin and the combined oral contraceptive pill was discontinued. The patient was treated with carotid endarterectomy within a week and Aspirin monotherapy was continued after surgery. Intraoperative findings confirmed the presence of a CaW associated to an atherosclerotic plaque (Figure 3). Histological examination of this sample revealed intimal hyperplasia with infiltration of spumous macrophages (Figure 4). Follow-up at four months revealed no recurrent neurological symptoms.

   

Figure 1: CTA of head and neck.

Presence of an intraluminal shelf-like protrusion in the posterior wall of the left carotid artery bulb on (A) axial and (B) sagittal images (red arrow), consistent with the diagnosis of CaW.

 

Figure 2: Brain MRI.

T1FS imaging of the cervical vessels showing a nonstenotic atherosclerotic plaque with signs of intraplaque haemorrhage along the posterior wall of the left carotid artery bulb (red arrow).

 

Figure 3: Intraoperative findings during carotid endarterectomy.

Intraoperative findings confirmed the presence of a Caw (thick black arrow) and an atherosclerotic plaque (thin black arrow).