Faculty Bibliography

A 4-month-old, full-term girl was referred for evaluation of a supraumbilical raphe and an anomalous aortic arch. Further work up for PHACE(S) syndrome was pursued, despite the absence of a cutaneous infantile hemangioma (IH), which identified hypoplastic and dysplastic cerebral vasculature. We present this case to raise awareness of possible PHACE(S) syndrome even in children without cutaneous IHs and the importance of recognizing supraumbilical raphe as a sentinel finding.

BACKGROUND:Carotid webs are increasingly recognized as a cause of ischemic stroke, but less is known about morphologically similar lesions in other arteries. We present the first study characterizing the clinical and radiographic features of extra-carotid arterial webs through a single-center case series and systematic review. METHODS:Patients with possible extra-carotid webs were identified from 2017 to 2025 using a natural language processing search of radiology reports at our institution. Candidate cases underwent imaging review with multiplanar and 3-dimensional reconstructions to distinguish webs from fenestrations, vessel tortuosity, dissection, or atherosclerotic plaque. In parallel, we performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review (Web of Science and PubMed, inception to September 2025) to identify published cases of extra-carotid web. Data on demographics, vascular location, imaging modality, clinical presentation, treatment, and outcomes were extracted and synthesized descriptively. RESULTS:Four extra-carotid webs were identified at our institution (3 basilar and 1 subclavian). None were associated with stroke, and all patients remained stable on conservative management during 9 months to 4 years of follow-up. Across 16 published studies, 22 additional extra-carotid webs were identified, yielding 26 patients in aggregate (mean age, 52.7 years; 61.5% male). The vertebral artery was the most common site (53.8%), followed by the basilar (30.8%) and subclavian (15.4%) arteries. Ten patients with vertebral or basilar web presented with posterior circulation ischemic stroke, with recurrent events in 4 patients. Most patients were managed with antiplatelet therapy or observation, while 3 vertebral webs with recurrent stroke were successfully treated with stenting. CONCLUSIONS:Extra-carotid webs share morphological and clinical features with carotid webs and may represent a unified disease spectrum of cervical artery webs. Vertebral and basilar webs, though rare, may be an underrecognized source of posterior circulation stroke. Recognition of these lesions may broaden the differential for cryptogenic stroke though the lack of histopathologic visualization remains a critical limitation of our study.

BACKGROUND:Carotid webs are increasingly recognized as a significant cause of cryptogenic stroke in young adults, yet they remain frequently underdiagnosed due to their subtle radiographic appearance and atypical presentations. The natural history of untreated carotid webs includes high rates of recurrent ipsilateral ischemic events despite optimal medical therapy. OBSERVATIONS/METHODS:The authors present the case of a 44-year-old man with four recurrent right hemispheric ischemic events over 5 years. Despite multiple angiographic studies, an underlying carotid web was initially misinterpreted. Digital subtraction angiography ultimately revealed a subtle posterolateral carotid web. Prior to endarterectomy, intraoperative ultrasound uniquely visualized a large thrombus adherent to the web, a critical finding not appreciated on preoperative angiography. Successful en bloc removal of the web and thrombus was performed with histopathological confirmation. The patient remained stroke free at the 1-year follow-up. LESSONS/CONCLUSIONS:Atypical carotid webs may lack classic radiographic features and can be misclassified on noninvasive imaging. Intraoperative ultrasound provides real-time assessment of thrombus burden not visible on preoperative angiography, allowing for improved surgical planning. This case demonstrates that web-associated thrombi are dynamic and may not be apparent even on high-resolution angiography performed shortly before surgery. Surgical intervention with intraoperative ultrasound guidance offers definitive treatment and excellent long-term outcomes. https://thejns.org/doi/10.3171/CASE2610.

Carotid webs are increasingly recognized as an underdiagnosed etiology of ischemic stroke, especially in young, otherwise healthy patients. These fibrous intimal protrusions create regions of flow stasis within the internal carotid artery, predisposing to thromboembolism. Diagnosis remains challenging due to their subtle radiographic appearance and underappreciation in clinical practice. While antiplatelet therapy or anticoagulation used to be the cornerstone of management, medical therapy alone has been found to be insufficient for stroke prevention in symptomatic patients. Definitive intervention includes carotid artery stenting or carotid endarterectomy; both have demonstrated excellent safety and efficacy. Risk stratification for symptomatic and asymptomatic carotid webs remains an area of active research, with emerging evidence suggesting that specific anatomic features, termed the carotid web angioarchitecture, may help predict stroke risk. Further studies are needed to determine the role of preventative intervention. A deeper understanding of carotid web pathogenesis, natural history, and hemodynamic impact is critical for guiding clinical decision-making.

BACKGROUND:The incidence of chronic subdural hematomas (cSDHs) is rising, leading to an increased reliance on imaging for diagnosis and management. CT imaging is commonly used in the evaluation of these patients, but transient enhancement of chronic subdural collections can mimic acute-on-chronic subdural hematomas, potentially leading to misdiagnosis. OBJECTIVE:To describe cases of transient enhancement of cSDHs after contrast administration. METHODS:A case series of three patients with pre-existing cSDHs was analyzed. One patient underwent middle meningeal artery embolization (MME), and two patients received contrast-enhanced CT (CECT) for other indications. Changes in subdural collection attenuation were assessed on serial imaging. RESULTS:These three patients with cSDH demonstrated transient enhancement of their subdural collections, which could be mistaken for acute or acute-on-chronic hemorrhage. Recognition of this pattern is critical to avoid misinterpretation, unnecessary radiation exposure, excessive healthcare utilization, and potentially invasive procedures. CONCLUSION/CONCLUSIONS:Awareness of transient enhancement in chronic subdural collections on CECT is essential for accurate diagnosis. Differentiating this benign imaging artifact from true hemorrhage can prevent unnecessary interventions and optimize patient care.

Meningiomas are the most common primary intracranial tumors and can be associated with significant morbidity and mortality. Radiologists, neurosurgeons, neuro-oncologists, and radiation oncologists rely on brain MRI for diagnosis, treatment planning, and longitudinal treatment monitoring. However, automated, objective, and quantitative tools for non-invasive assessment of meningiomas on multi-sequence MR images are not available. Here we present the BraTS Pre-operative Meningioma Dataset, as the largest multi-institutional expert annotated multilabel meningioma multi-sequence MR image dataset to date. This dataset includes 1,141 multi-sequence MR images from six sites, each with four structural MRI sequences (T2-, T2/FLAIR-, pre-contrast T1-, and post-contrast T1-weighted) accompanied by expert manually refined segmentations of three distinct meningioma sub-compartments: enhancing tumor, non-enhancing tumor, and surrounding non-enhancing T2/FLAIR hyperintensity. Basic demographic data are provided including age at time of initial imaging, sex, and CNS WHO grade. The goal of releasing this dataset is to facilitate the development of automated computational methods for meningioma segmentation and expedite their incorporation into clinical practice, ultimately targeting improvement in the care of meningioma patients.

Brown syndrome is the inability to gaze upward beyond the horizontal level while adducting the eye due to an abnormality of the superior oblique tendon sheath complex. It is a rare extraocular muscular disorder, and its imaging is infrequently seen in radiologic practice. This article presents clinical characteristics and imaging of 5 patients with Brown syndrome and reviews the radiologic literature available, to familiarize the readers with its imaging findings.

There are multiple treatment alternatives for cavernous dAVFs, with transvenous routes being most common. Among these routes, occluded inferior petrosal sinus is well-described, and, apart from being imaginative and elegant, it is also safe and effective. Herein we describe the application of this method to reach the fistulous pouch of a cavernous dAVF via an occluded superior petrosal sinus.