Carotid artery web and ischemic stroke: A case-control study

Objective: To determine whether there is an association between carotid artery web and ischemic stroke. Methods: This was a single-center, age- and sex-matched, case-control study. Cases were consecutive patients with anterior circulation ischemic stroke of undetermined etiology (Trial of Org 10172 in Acute Stroke Treatment [TOAST] classification). Controls were consecutive patients with cerebral aneurysms, arteriovenous malformations, or primary intracerebral hemorrhages. Additional inclusion criteria were age <60 years and CT angiography of the neck. Two neuroradiologists diagnosed webs according to previously published criteria. One neuroradiologist also assessed for nonstenotic atherosclerotic plaque (carotid wall thickness ≥3 mm or intramural calcification). We used conditional logistic regression to estimate the odds ratio between carotid web and ischemic stroke and its 95% confidence interval. Results: Fifty-three of 62 cases (85%) were matched by age (within 1 year) and by sex to 102 controls. There was a carotid web in 4 of 53 cases (9.4%) vs 1 of 102 controls (1.0%, odds ratio = 8.0, 95% confidence interval = 1.2-67, p = 0.032). There was no significant difference in the prevalence of nonstenotic carotid atherosclerotic plaque between the case and control groups. There was agreement on diagnosis of web for 163 of 164 patients (99%) and 7 of 8 webs (88%), and the Cohen for interobserver agreement was 0.93. Conclusions: There is an association between carotid artery web and ischemic stroke in patients who lack an alternative cause of stroke. Carotid web may be an underappreciated risk factor for stroke

Nonstenotic carotid plaque on CT angiography in patients with cryptogenic stroke

Objective: To determine whether large (≥3 mm thick) but nonstenotic (<50%) carotid artery atherosclerotic plaque predominantly occurs ipsilateral rather than contralateral to cryptogenic stroke. Methods: This was a cross-sectional observational study. Using a stroke registry, we identified consecutive patients with anterior circulation embolic stroke of undetermined source (ESUS). Using CT angiography, we measured carotid plaque size (thickness, mm) and carotid artery stenosis (North American Symptomatic Carotid Endarterectomy Trial method) for each patient. We dichotomized plaque size at several predefined thresholds and calculated the frequency of plaque size above each threshold ipsilateral vs contralateral to stroke. Results: We included 85 patients with ESUS. Plaque with thickness ≥5 mm was present ipsilateral to stroke in 11% of patients, and contralateral in 1% (9/85 vs 1/85; p 0.008). Plaque with thickness ≥4 mm was present ipsilateral to stroke in 19% of patients, and contralateral in 5% (16/85 vs 4/85; p 0.002). Plaque with thickness ≥3 mm was present ipsilateral to stroke in 35% of patients, and contralateral in 15% (30/85 vs 13/85; p 0.001). There was no difference in percentage stenosis ipsilateral vs contralateral to stroke (p 0.98), and weak correlation between plaque size and stenosis (R 2 0.26, p < 0.001). Conclusions: Large but nonstenotic carotid artery plaque is considerably more common ipsilateral than contralateral to cryptogenic stroke, suggesting that nonstenotic plaque is an underrecognized cause of stroke. We measured plaque size using CT angiography, a method that could be easily implemented in clinical practice