Faculty Bibliography

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.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Carotid webs are an underrecognized cause of ischemic stroke in young adults and are associated with a high risk of recurrence when managed with medical therapy alone. Although carotid endarterectomy (CEA) is increasingly performed, histopathological confirmation remains infrequently reported, and the underlying pathological substrate of symptomatic carotid webs is not well defined. In this study, we present the largest pathologically confirmed series of symptomatic carotid webs treated with CEA, providing a comprehensive clinicopathological characterization and evaluation of long-term surgical outcomes. METHODS:Patients with symptomatic carotid webs were retrospectively identified from institutional databases encompassing both inpatient and outpatient encounters. Clinical features, imaging characteristics, surgical findings, and histopathological results from CEA specimens are presented. RESULTS:Among 39 patients with symptomatic carotid web, 34 underwent CEA with histopathological confirmation of the diagnosis, characterized by focal eccentric intimal fibromyxoid tissue, fibromuscular dysplasia, hyperplasia, or thickening. Notably, concurrent atheromatous changes were noted in 6 patients. All webs were located within 3 cm of the carotid bifurcation, and most (76%) were localized on the posterior wall. Competing stroke mechanisms were identified in 15% of patients. Two-thirds of patients presented with a large or medium vessel occlusion and over half received acute reperfusion therapy (intravenous thrombolysis and/or mechanical thrombectomy). Two patients experienced transient, minor cranial nerves injuries (hypoglossal nerve and marginal mandibular branch) after CEA. At a median follow-up of 29 months, no patients experienced recurrent stroke (95% CI: 0%-10%), and the median modified Rankin Scale score was 1 (0-1). CONCLUSION/CONCLUSIONS:This study supports CEA as a safe and effective therapeutic option for patients with symptomatic carotid webs and demonstrates its diagnostic value through direct histopathological confirmation. By presenting the largest pathologically validated series to date, our findings further define the vascular pathology underlying carotid webs and underscore the diagnostic value of surgical resection for definitive diagnosis.

OBJECTIVE/UNASSIGNED:Carotid webs, first described in 1968, are increasingly recognized as a surgically treatable cause of ischemic stroke, particularly in young patients. Despite growing attention, the literature remains fragmented. We conducted the first advanced bibliometric analysis of carotid web research to map its historical foundations, identify key contributors, and illustrate emerging trends. METHODS/UNASSIGNED:The Web of Science database (inception-2025) was queried for carotid web publications. Articles and metadata were analyzed using Bibliometrix (R) and Python libraries. Reference publication year spectroscopy (RPYS) was employed to analyze the field's roots by analyzing citation frequency by publication year. RESULTS/UNASSIGNED:A total of 281 publications from 109 sources and 1,129 authors were identified. Annual publication growth averaged 6.15%, with 90% published after 2016. International collaboration was modest (9-11%), led by the U.S., China, France, and Canada. Shifts in keyword frequency reflected the field's evolution from early nosological uncertainty toward recognition of carotid webs as a distinct, high-risk lesion underlying ischemic stroke. Stroke and Journal of Vascular Surgery emerged as early key sources. Author analysis identified the most prolific contributors, though coauthorship networks remained small. RPYS revealed 19 seminal studies (1968-2021) that shaped the field's progression from early pathology descriptions to recognition of carotid webs as high-risk lesions for stroke. CONCLUSIONS/UNASSIGNED:Carotid web research has rapidly expanded, evolving into a multidisciplinary field. RPYS identified 19 seminal publications tracing the intellectual trajectory of the field. Ongoing challenges include limited collaboration, unresolved questions of pathogenesis, and variability in terminology and diagnostic criteria.

BACKGROUND:Recent guidelines suggest that aspirin-ticagrelor may be considered for stroke prevention after mild acute ischemic stroke. However, it is unclear how commonly this dual antiplatelet therapy (DAPT) regimen is used in practice. METHODS:We performed a cross-sectional analysis of the Get With The Guidelines-Stroke registry 2017-2023. Patients with a non-cardioembolic mild ischemic stroke (defined as NIHSS <6) who presented within 24 hours of last known well without a contraindication to DAPT were included. The primary study outcome was the proportion of patients prescribed aspirin-ticagrelor at hospital discharge; temporal patterns of prescribing aspirin-ticagrelor and aspirin-clopidogrel over time are also described. In addition to standard tests of comparison, we used multiple logistic regression to evaluate associations between patient and facility factors and aspirin-ticagrelor use reported as odds ratios (OR) with 95% confidence intervals (CI). RESULTS:Among 1,018,736 patients meeting study criteria, 478,049 (46.9%) were female and median age was 68 (IQR: 59, 78) years. A total of 12,845 (1.3%) patients were discharged on aspirin-ticagrelor whereas 448,348 (44.0%) were discharged on aspirin-clopidogrel. Prescriptions for aspirin-ticagrelor and for aspirin-clopidogrel significantly increased over the study time-period. In regression analysis, coronary artery disease/prior myocardial infarction (OR: 2.6 [95% CI: 2.5-2.7]), Asian race (OR: 2.1 [95% CI: 1.9-2.2]), aspirin-clopidogrel prescription upon admission (OR: 2.0 [95% CI:1.9-2.1]), and history of stroke/TIA (OR: 1.98 [95% CI: (1.9-2.1)]), were substantially associated with aspirin-ticagrelor use whereas lacking insurance/self-pay (OR: 0.7 [95% CI: 0.6-0.8]), rural setting (OR: 0.8 [95% 0.7-0.9]), and primary stroke centers (OR: 0.3 [95% CI: 0.3-0.4]) were inversely associated with aspirin-ticagrelor. In the subgroup of 176,897 (17.4%) patients with NIHSS 4-5, 74,912 (50.8%) were discharged on aspirin-clopidogrel and 2,394 (1.4%) on aspirin-ticagrelor. CONCLUSION/CONCLUSIONS:Unlike aspirin-clopidogrel, aspirin-ticagrelor is infrequently administered after mild acute ischemic stroke (NIHSS <6) despite current guidelines, though the use of both DAPT regimens increased over time.

OBJECTIVE:The cause of perimesencephalic subarachnoid hemorrhage (pmSAH) is unclear but has historically been attributed to a venous source. The authors hypothesized that high-resolution cone-beam CT (CBCT) during angiography could better identify pmSAH etiology. METHODS:All patients with pmSAH treated at the authors' institution between January 2023 and December 2024 were retrospectively analyzed. Patients were excluded if CBCT was not performed as part of the digital subtraction angiography (DSA), if CBCT source data were not available for review, or if the images were deemed to be low quality. All images were reviewed by 2 neuroangiographers with extensive neurovascular imaging experience and discussed until consensus agreement. Data were recorded as counts and percentages. RESULTS:Among 152 patients who presented with spontaneous SAH in 2023-2024, 22 had a pmSAH defined according to the Rinkel criteria. These 22 patients had a catheter angiogram performed on 1 of 2 biplane machines. Thirteen of those patients had high-quality CBCT data available for review, 8 (61%) of whom were found to harbor a basilar perforator focal outpouching consistent with a site of rupture. All patients with pmSAH, including the 8 found to have a basilar perforator aneurysm, achieved an excellent neurological recovery with resolution of the basilar perforator finding on follow-up DSA with CBCT and without experiencing a re-rupture event or clinically significant vasospasm. CONCLUSIONS:In the setting of pmSAH, high-resolution CBCT acquired as part of catheter angiography frequently identifies a basilar perforator pseudoaneurysm. Conservative management was associated with excellent outcomes in this series. The authors propose that in the setting of pmSAH, a high suspicion of an arterial etiology should be considered until proven otherwise.

OBJECTIVE:To validate the carotid web (CW) risk stratification assessment described in previous works within a larger cohort of patients with symptomatic and incidentally found asymptomatic CWs. METHODS:A retrospective analysis of our institution's electronic medical records identified all patients with a diagnosis of CW from 2017 to 2024. We included symptomatic patients and those with asymptomatic CWs, that is, incidentally found webs without history of stroke or transient ischemic attack. Patient charts were reviewed for demographics, imaging, comorbidities, and a diagnosis of stroke after diagnosis of asymptomatic CW. All angles were measured as described in previous work on a sagittal reconstruction of neck CT angiography in which the common carotid artery (CCA), external carotid artery, and internal carotid artery (ICA) were well visualized, together with the CW itself. Principal component analysis and logistic regression were performed to evaluate the association between high-risk angles and stroke risk.  RESULTS: Twenty-six symptomatic and 26 asymptomatic patients were identified. Of note, the number of patients with hypertension, hyperlipidemia, and smoking history was 17 (65.0%), 16 (62.0%), and 8 (31.0%) for symptomatic patients and 18 (69.0%), 17 (65.0%), and 15 (58.0%) for asymptomatic patients. All angular measurements showed statistically significant associations with stroke status. The CCA-web-pouch angle showed the strongest association (p=2.07×10⁻⁴), followed by the CCA-pouch-tip angle (p=3.23×10⁻⁴), ICA-web-pouch angle (p=0.004), and ICA-pouch-tip angle (p=0.005). Each additional high-risk angle increased the odds of stroke by 9.47-fold (p<0.0001). The associated probability of stroke increased from 6.3% with no high-risk angles to 39.1% with one high-risk angle and further to 85.9% with two high-risk angles. The model demonstrated high sensitivity, correctly identifying 84.6% of positive cases, and high specificity, correctly identifying 88.5% of negative cases. The F1 score was 0.863, indicating good overall model performance.  CONCLUSION: Given this successful stratification of CWs into high- and low-risk groups, the utilization of geometric CW parameters may play a role in improving patient selection for intervention in the setting of incidentally diagnosed CW. .

Despite continued advancement in thrombectomy devices and techniques, a small proportion, approximately 10%, of thrombectomy attempts result in failed reperfusion due to technical difficulties with reaching the clot or recanalizing the occluded vessel. Technically challenging thrombectomy cases are often longer, with more thrombectomy passes, resulting in poorer clinical outcomes and higher rates of complications. Factors causing difficulty during thrombectomy include tortuous vasculature preventing access, challenging clot location (tandem or distal occlusions), underlying vessel abnormality, and hard-to-retrieve clots. Anticipating potentially challenging or refractory thrombectomy cases allows one to plan appropriate procedural strategies with the goal of maximizing technical success and favorable clinical outcome. We review these challenging situations and discuss specific procedural techniques that can be employed in each scenario to overcome the barriers and achieve fast and successful reperfusion.

INTRODUCTION AND PROBLEM STATEMENT/UNASSIGNED:A chief resident's role incorporates administrative, academic, and interpersonal responsibilities essential to managing a successful residency program. However, rising chief residents receive little formal exposure to leadership training. OBJECTIVES/UNASSIGNED:To (1) define leadership styles; (2) understand the effect of cultural competence on leadership styles; (3) learn effective methods to advocate as the chief resident; (4) provide effective peer feedback; (5) provide effective supervisor feedback; (6) learn effective conflict management; (7) ensure psychological safety. METHODS AND CURRICULUM DESCRIPTION/UNASSIGNED:We developed a 1-day curriculum combining didactics and simulation activities for our program's rising chief residents. Implementation of our curricular design included a morning session focusing on small groups and didactic-based lectures on specific topics pertinent to leadership, along with a debriefing of a psychometric evaluation tool administered before the curriculum day. The simulation activity consisted of 3 group objective structured clinical examination (G-OSCE) scenarios: (1) providing a struggling junior trainee with feedback; (2) debriefing an adverse clinical outcome as the team leader; (3) navigating a challenging situation with a supervising physician. Standardized participants were surveyed for specific objectives. Learners completed precurricular and postcurricular surveys on their familiarity and preparedness for their chief year. RESULTS AND ASSESSMENT DATA/UNASSIGNED:= 0.421), learner-reported use of wellness resources was noted to be reduced after the curricular intervention and remains a result of further interest for exploration. DISCUSSION AND LESSONS LEARNED/UNASSIGNED:A 1-day leadership development curriculum combining didactics and simulation is an effective means of preparing rising chief residents to succeed in their transition to this leadership role.