Ultrasonography Shines Light on Carotid Thrombus Before Surgical Intervention

A 44‐year‐old man with a history several right middle cerebral artery (MCA) ischemic events was referred to our comprehensive stroke center's clinic. His first neurovascular event occurred five years prior when he experienced transient left‐sided numbness and was diagnosed with a transient ischemic attack (TIA). Non‐contrast head CT (NCHCT) was negative for ischemia; neither MRI nor vessel imaging was obtained. He was discharged on aspirin. Three years later he presented with similar symptoms. NCHCT showed an acute right temporal lobe infarct and chronic right hemispheric watershed injury. CT angiogram (CTA) demonstrated an intraluminal thrombus adherent to the posterior wall of the internal carotid artery (ICA) near the carotid bulb. He was again discharged on aspirin. One year later he presented again with similar symptoms. CTA demonstrated a patent cervical right ICA but occlusion of the right M1 segment. He received thrombolysis, underwent thrombectomy and was discharged on aspirin and clopidogrel. Finally, he was admitted with his fourth ischemic event ‐ a completed right M2 occlusion. CTA was again interpreted as unremarkable. When seen in our clinic, the pattern of recurrent right hemispheric neurovascular events in a young patient and prior cervical ICA intraluminal thrombus raised concern for an “atypical carotid web” (ACW). He underwent digital subtraction angiography (DSA) which confirmed our suspicion (Figure 1). Our patient underwent right carotid endarterectomy (CEA) for definitive secondary stroke prevention. Immediately prior to the incision, ultrasound was used to locate the carotid bulb and incidentally visualized the web with a large adherent thrombus not seen on the prior DSA (Figure 2). Dissection of the vessels was undertaken very carefully to maintain the fragile thrombus. Upon opening the vessel, the thrombus was visualized. It was removed, along with the underlying web, during the endarterectomy. The patient woke up from the operation with a stable exam. image image