Spontaneous asymptomatic common carotid artery dissection resembling a carotid web: illustrative case

Abstract

Background: Carotid artery dissection is a common cause of ischemic stroke, predominantly affecting the internal carotid artery, with rare involvement of the common carotid artery (CCA). The limited literature makes diagnosis and management challenging, particularly in asymptomatic patients. In this report, the authors present a unique case of spontaneous, asymptomatic CCA dissection that resembled a carotid web, shedding light on its clinical spectrum and management.

Observations: A 70-year-old man was diagnosed with an intimal flap in the left CCA. Although the findings resembled those of a carotid web, cerebral angiography confirmed the presence of an intimal flap and arterial wall irregularities indicative of vascular dissection. Endarterectomy successfully prevented the stroke, and the postoperative recovery was uneventful. Pathological examination confirmed the diagnosis of CCA dissection.

Lessons: Spontaneous CCA dissection, though rare, presents significant diagnostic and therapeutic challenges. Because of morphological similarities, differentiating the diagnosis from a carotid web can be difficult. Available treatment strategies include antiplatelet therapy and surgical intervention. In this case, endarterectomy was chosen to avoid antithrombic treatment in anticipation of further invasive treatments for other conditions. The successful outcome highlights the potential as a treatment option, emphasizing the need for an individualized approach to each patient. https://thejns.org/doi/10.3171/CASE24344.

Keywords: carotid web; common carotid artery; dissection; intimal flap.

FIG. 1.

Neck ultrasound showing an intimal flap protruding into the lumen of the left CCA (arrow).

FIG. 2.

Three-dimensional (3D) CT angiography of the cervical blood vessels (A) and cervical magnetic resonance (MR) angiography (B) demonstrate vessel wall irregularities in the left CCA (circle, arrow). Axial time-of-flight MR angiography shows a double lumen (C, arrowhead). Left CCA, anteroposterior view (D), and 3D rotational angiography, axial view (E), show an intimal flap and a double lumen on the posterior outer wall of the CCA, distal to the carotid bulb (double arrows, double arrowheads).

FIG. 3.

Intraoperative images. A: The CCA, internal carotid artery, and external carotid artery are exposed. The area with the intimal flap (arrow) appears slightly swollen, though the adventitia is well preserved. B: The CCA is incised, revealing the intimal flap (double arrows). C: The intimal flap is resected.

FIG. 4.

A pathological image of the excised specimen demonstrates a portion of the intima (arrowhead) detached from the internal elastic plate (arrow), indicating vascular dissection. Elastica van Gieson stain.