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A previously independent 47-year-old woman presented to the emergency department with left face and upper limb sensorimotor deficits. Her initial National Institutes of Health Stroke Scale (NIHSS) score was 11 points and CT scan of the head excluded a haemorrhagic lesion. Unfortunately, late arrival at hospital contraindicated acute reperfusion therapy. MR scan of the brain showed an ischaemic stroke involving the deep right middle cerebral artery territory with ipsilateral encephalomalacia.
Six years previously she had developed a right hemisphere ischaemic stroke with subsequent complete motor recovery. The event had been deemed cryptogenic after a negative full workup. She was discharged on aspirin 100 mg daily but stopped this herself.
On both occasions, a CT angiogram had been reported as unremarkable. However, review of the sagittal images identified a linear filling defect in the right extracranial internal carotid artery (ICA) (figure 1A). A previous ultrasound scan of the neck had identified an abnormal protrusion into the extracranial ICA lumen at this site, originally interpreted as a small atheromatous plaque (figure 1B). Digital subtraction angiography confirmed a carotid web in the extracranial right ICA with 50% luminal stenosis (figure 1C) and …
Contributors MM: conceived and designed the analysis, collected the data and wrote the paper. SS, FP and CC: reviewed the paper. All authors discussed the results and contributed to the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned. Externally peer reviewed by William Whitely, Edinburgh, UK.