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Web Browsing: High-Speed Diagnosis and Treatment of Carotid Artery Web

Background: Although carotid artery web (CaW) was initially described in 1973 as a potential etiology of ischemic stroke, it still remains underrecognized. Because CaW is a membrane affixed perpendicularly from the carotid wall that projects out into the lumen above the bifurcation, it typically is not stenotic, and hence, utilizing only 1 vessel imaging modality during conventional stroke workup may instead lead to a diagnosis of ESUS: embolic stroke of undetermined source. The term ESUS was created in 2014 by researchers to define a subset of cryptogenic, nonlacunar (embolic-appearing) strokes without clear cardiac or vascular cause. Purpose: In this review, we describe how, after multiple evaluations of vessels, CaW was diagnosed in relatively young patients (age 39-47 years old, without significant vascular risk factors) in whom otherwise were considered embolic stroke of undetermined source. This observation dovetails with the accompanying Neurohospitalist article entitled, “Delayed Thrombus Formation on Carotid Web and Its Medical and Endovascular Management for Secondary Stroke Prevention.” Research Design: Not applicable. Case review. Results/Conclusion: This report demonstrates the futility of antiplatelet therapy for a young patient with CaW-related stroke. Based on these collective experiences and review of the literature, we postulate that: (1) multiple vascular imaging modalities during stroke workup may result in a CaW diagnosis instead of ESUS; (2) young stroke patients without traditional vascular risk factors are candidates for this “web browsing” of extended imaging of vessels; and (3) carotid artery stenting (CAS) or carotid endarterectomy (CEA) may be preferred as first-line over medical therapy alone (ie, antiplatelet or anticoagulation) because CEA/CAS addresses the stroke etiology, CaW, definitively.