Seminars in NeurologyPub Date : 2026-08-01Epub Date: 2026-01-27DOI: 10.1055/a-2789-0211
Elise N Snyder, Geetha Jeyabalan
{"title":"Common Carotid Disease and Interventions.","authors":"Elise N Snyder, Geetha Jeyabalan","doi":"10.1055/a-2789-0211","DOIUrl":"10.1055/a-2789-0211","url":null,"abstract":"<p><strong>Abstract: </strong>Common carotid artery (CCA) disease represents a challenging subset of cerebrovascular pathology with unique anatomical and hemodynamic considerations distinct from the more extensively studied internal carotid artery stenosis. Stenosis at the CCA origin from the aortic arch occurs with an approximate incidence of 0.5 to 6.4% of angiographic imaging cases, with approximately 17% of symptomatic patients developing tandem disease involving the carotid bifurcation. The pathophysiology of stroke risk involves hemodynamic compromise, embolic phenomena, and the cumulative effects of multilevel disease, although natural history data remain limited. Management decisions are guided primarily by observational data and expert consensus due to the absence of randomized controlled trials. Current evidence-based guidelines recommend optimal medical management for asymptomatic patients and reserve intervention for symptomatic individuals. When intervention is pursued, an \"endovascular-first\" approach is favored based on systematic review data showing lower 30-day mortality and stroke rates compared with open surgery, despite higher restenosis rates (9 vs. 1.3%). However, endovascular treatment of tandem lesions increases stroke and death risk in asymptomatic patients. Hybrid procedures combining open and endovascular techniques demonstrate intermediate outcomes but elevated risk in symptomatic patients. Treatment selection requires individualized assessment incorporating symptom status, lesion characteristics, technical feasibility, patient anatomy, and surgeon experience. Substantial knowledge gaps persist regarding natural history, long-term comparative effectiveness, optimal management of tandem disease, and the evolving role of contemporary medical therapy, underscoring the need for continued investigation in this complex area of vascular medicine.</p>","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":" ","pages":"374-380"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146068249","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Seminars in NeurologyPub Date : 2026-08-01Epub Date: 2025-11-17DOI: 10.1055/a-2735-9854
Bryan Bo-Ran Ho, Paola Batarseh, Alan Dardik
{"title":"Pathophysiology of Atherosclerotic Carotid Disease.","authors":"Bryan Bo-Ran Ho, Paola Batarseh, Alan Dardik","doi":"10.1055/a-2735-9854","DOIUrl":"10.1055/a-2735-9854","url":null,"abstract":"<p><strong>Abstract: </strong>Carotid artery atherosclerosis is an important etiology of carotid artery stenosis and subsequent cerebrovascular events. Carotid atherosclerosis follows a pattern that begins with endothelial dysfunction, marked by impaired nitric oxide-mediated vasodilation and increased endothelial permeability, and is followed by intimal low-density lipoprotein (LDL) accumulation. Retained oxidized LDL results in a pro-inflammatory environment that results in inflammatory cell inflammation and foam cell formation, the basis of the fatty streak. Migrating medial vascular smooth muscle cells, which undergo phenotypic switching, lead to plaque growth and fibrous cap formation. The unique geometry of the carotid bifurcation contributes to the complex local hemodynamic environment and predisposes the carotid bifurcation to endothelial dysfunction. In later stages of atherosclerosis, higher wall shear stress erodes the fibrous cap and increases the risk of plaque rupture. Several parameters of carotid bifurcation geometry, including the bifurcation angle and relative diameters of the internal and common carotid arteries, also contribute to disturbed flow and atherosclerotic plaque development.</p>","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":" ","pages":"326-335"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12959083/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145543645","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Seminars in NeurologyPub Date : 2026-08-01Epub Date: 2026-01-13DOI: 10.1055/a-2786-3743
Paola Batarseh, Judy Li, David Strosberg
{"title":"Carotid Body Tumors.","authors":"Paola Batarseh, Judy Li, David Strosberg","doi":"10.1055/a-2786-3743","DOIUrl":"10.1055/a-2786-3743","url":null,"abstract":"<p><strong>Abstract: </strong>Carotid tumors are rare, hyper-vascular structures arising from the chemoreceptors of the carotid body. In this study, we will discuss the classification and diagnosis of carotid body tumors, as well as surgical resection, which is the definitive treatment for these lesions. We will highlight important preoperative considerations to minimize the risk of bleeding, cranial nerve injury, and stroke with surgical resection.</p>","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":" ","pages":"409-412"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145967611","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Seminars in NeurologyPub Date : 2026-08-01Epub Date: 2026-04-07DOI: 10.1055/a-2828-9116
Luca Saba, Alessandro Pinna, Jasjit S Suri, Kosmas I Paraskevas
{"title":"Carotid Imaging: Current Concepts and Advanced Imaging.","authors":"Luca Saba, Alessandro Pinna, Jasjit S Suri, Kosmas I Paraskevas","doi":"10.1055/a-2828-9116","DOIUrl":"10.1055/a-2828-9116","url":null,"abstract":"<p><strong>Abstract: </strong>Carotid atherosclerosis is a major cause of ischemic stroke, historically managed according to luminal stenosis severity. However, stenosis alone fails to capture plaque biology, as features such as intraplaque hemorrhage (IPH), lipid-rich necrotic core, fibrous cap rupture, ulceration, and perivascular inflammation strongly influence vulnerability and clinical outcomes. Advances in imaging have shifted the focus from lumen quantification to multimodal plaque phenotyping. Ultrasound, computed tomography angiography (CTA), magnetic resonance imaging (MRI), digital subtraction angiography, photon-counting CT (PCCT), and positron emission tomography (PET) provide complementary morphological and biological information, while contrast-enhanced ultrasound, radiomics, and artificial intelligence (AI) enhance risk stratification beyond conventional parameters. MRI remains the reference for detecting IPH, while CTA and PCCT improve lumen and tissue characterization. PET tracers further interrogate inflammatory and calcification pathways. Emerging frameworks such as Plaque-Reporting and Data System aim to standardize reporting and integrate multimodal biomarkers. The future of carotid imaging lies in precision medicine, combining advanced imaging, AI, and molecular biology to optimize individualized stroke prevention strategies.</p>","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":" ","pages":"336-345"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147634643","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Seminars in NeurologyPub Date : 2026-08-01Epub Date: 2026-04-23DOI: 10.1055/a-2848-3254
Jaims Lim, Vinay Jaikumar, Terry C Xia, Matthew Moser, Devan Patel, Lukasz Przepiorka, Andre Monteiro, Muhammad Waqas, Pui Man Rosalind Lai, Jason M Davies, Kenneth V Snyder, Elad I Levy, Adnan H Siddiqui
{"title":"Carotid Revascularization Protocol for Symptomatic Stenosis.","authors":"Jaims Lim, Vinay Jaikumar, Terry C Xia, Matthew Moser, Devan Patel, Lukasz Przepiorka, Andre Monteiro, Muhammad Waqas, Pui Man Rosalind Lai, Jason M Davies, Kenneth V Snyder, Elad I Levy, Adnan H Siddiqui","doi":"10.1055/a-2848-3254","DOIUrl":"10.1055/a-2848-3254","url":null,"abstract":"<p><strong>Abstract: </strong>Carotid endarterectomy (CEA) has been considered the standard of care for symptomatic carotid stenosis (sCS). Carotid artery stenting (CAS) warrants reevaluation for equivalence to CEA given advances in embolic protection and stent technology. Our patients with sCS undergo computed tomography angiography and perfusion, magnetic resonance imaging, and carotid duplex ultrasonography to guide selection for CEA, CAS, or transcarotid artery revascularization (TCAR). Preoperative management includes dual antiplatelet therapy and maximal-dose statin therapy, comorbidity optimization, smoking cessation counseling, cardiac risk assessment for stroke, systemic anticoagulation for an intraluminal thrombus, and perfusion-based risk stratification. For CAS, we routinely use dual embolic protection with proximal balloon occlusion and distal filters, second-generation micromesh stents, and poststenting aspiration. Intravascular lithotripsy and integrated embolic protection have broadened the indications for CAS. We present our algorithm for managing sCS, demonstrating CEA, CAS, and TCAR as equivalent in safety and effectiveness for most patients, while recognizing select factors conferring higher risk with each approach.</p>","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":" ","pages":"358-366"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147787280","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Seminars in NeurologyPub Date : 2026-08-01Epub Date: 2025-11-26DOI: 10.1055/a-2741-2575
Eric A Grin, Daniel D Wiggan, Michela Rosso, Vera Sharashidze, Charlotte Chung, Evan Stein, Maksim Shapiro, Eytan Raz, Jacob Baranoski, Howard A Riina, Caleb Rutledge, Erez Nossek
{"title":"Carotid Webs.","authors":"Eric A Grin, Daniel D Wiggan, Michela Rosso, Vera Sharashidze, Charlotte Chung, Evan Stein, Maksim Shapiro, Eytan Raz, Jacob Baranoski, Howard A Riina, Caleb Rutledge, Erez Nossek","doi":"10.1055/a-2741-2575","DOIUrl":"10.1055/a-2741-2575","url":null,"abstract":"<p><strong>Abstract: </strong>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.</p>","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":" ","pages":"391-404"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145642331","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Seminars in NeurologyPub Date : 2026-08-01Epub Date: 2026-04-09DOI: 10.1055/a-2843-6090
David M Greer
{"title":"Joseph Schindler, MD, and Charles Matouk, MD.","authors":"David M Greer","doi":"10.1055/a-2843-6090","DOIUrl":"10.1055/a-2843-6090","url":null,"abstract":"","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":" ","pages":"323"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147647352","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Non-stenotic Carotid Disease: Review of the Literature and Case Discussion of TCAR for Treatment.","authors":"Tiffany Chu, Khadija Soufi, Jose Castillo, Anzhela Moskalik, Clayton Gerndt, Branden J Cord","doi":"10.1055/a-2893-7436","DOIUrl":"10.1055/a-2893-7436","url":null,"abstract":"<p><strong>Abstract: </strong>Non-stenotic carotid disease represents an understudied yet clinically significant pathology. While stenosis is the primary mechanism underlying most strokes, other mechanisms such as thromboembolism from plaque rupture and carotid webs have been implicated in symptomatic non-stenotic carotid disease (SyNC). Studies have identified imaging features of high-risk non-stenotic plaques, but there is currently no standardized definition or imaging protocol for SyNC. Furthermore, despite current guidelines not recommending surgical intervention, an emerging body of literature suggests that carotid endarterectomy and carotid artery stenting may be safe and effective treatments for SyNC. In this review, we provide an overview of the existing knowledge on SyNC, including a recently proposed working definition, the underlying pathophysiology, characteristics of vulnerable plaques, and current management strategies. Additionally, we present a case from our institution using transcarotid artery revascularization (TCAR) to treat SyNC, which, to our knowledge, is the first such report in the literature.</p>","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":"46 4","pages":"367-373"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13400088/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148585628","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Seminars in NeurologyPub Date : 2026-08-01Epub Date: 2025-11-06DOI: 10.1055/a-2737-7618
Ekaterina Bakradze, Shadi Yaghi
{"title":"Carotid Dissection: Pathophysiology and Treatment.","authors":"Ekaterina Bakradze, Shadi Yaghi","doi":"10.1055/a-2737-7618","DOIUrl":"10.1055/a-2737-7618","url":null,"abstract":"<p><strong>Abstract: </strong>Cervical artery dissection is one of the leading causes of ischemic stroke in young adults, and poses unique diagnostic and therapeutic challenges due to an often nonspecific clinical presentation. Prompt recognition is essential, as early ischemic events are common within the first 2 to 4 weeks. This review summarizes current evidence on the epidemiology, pathophysiology, clinical features, diagnostic strategies, and management of cervical carotid artery dissections. While antithrombotic therapy is the mainstay of secondary stroke prevention, the optimal choice between antiplatelet and anticoagulation remains uncertain. Randomized trials and large cohort studies suggest similar efficacy between antiplatelet and anticoagulant therapies, though anticoagulation may confer benefit in patients with vessel occlusion. Recurrent dissection and ischemic events are rare, and dissecting aneurysms generally have a benign course. Endovascular intervention is reserved for select cases. A tailored, risk-based approach to therapy-guided by clinical and radiographic features-is essential to improve outcomes in this complex and heterogeneous population.</p>","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":" ","pages":"381-390"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145460468","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Seminars in NeurologyPub Date : 2026-08-01Epub Date: 2025-09-01DOI: 10.1055/a-2685-3141
Abdelaziz Amllay, Andrew B Koo, Daniela Renedo, Varun Padmanaban, Ben Teasdale, Ryan M Hebert, Anil Arat, Taylor Duda, Joseph Schindler, Christopher J Stapleton, James D Rabinov, Aman B Patel, Charles C Matouk, Nanthiya Sujijantarat
{"title":"Carotid Revascularization in the Modern Era: A Comparative Review of Carotid Endarterectomy, Carotid Angioplasty and Stenting, and Transcarotid Artery Revascularization.","authors":"Abdelaziz Amllay, Andrew B Koo, Daniela Renedo, Varun Padmanaban, Ben Teasdale, Ryan M Hebert, Anil Arat, Taylor Duda, Joseph Schindler, Christopher J Stapleton, James D Rabinov, Aman B Patel, Charles C Matouk, Nanthiya Sujijantarat","doi":"10.1055/a-2685-3141","DOIUrl":"10.1055/a-2685-3141","url":null,"abstract":"<p><strong>Abstract: </strong>Carotid artery stenosis is a major cause of acute ischemic stroke, accounting for approximately 15% of cases. Although optimal medical therapy remains the cornerstone of management, current guidelines recommend consideration of surgical intervention for symptomatic patients with ≥50% stenosis and asymptomatic patients with ≥70% stenosis. Extensive evidence supports carotid endarterectomy (CEA) as the gold standard procedure, whereas transfemoral carotid angioplasty and stenting (TF-CAS) and transcarotid artery revascularization (TCAR) offer safe alternatives for patients with high surgical risk. Emerging data suggest that TCAR provides safety and efficacy profiles comparable to CEA and superior to TF-CAS in select patients. Considering these findings, selecting an appropriate revascularization strategy should rely on a multidisciplinary, individualized risk-benefit assessment. This article aims to provide a comparative review of the latest evidence on clinical indications, surgical techniques, and outcomes for current carotid revascularization strategies.</p>","PeriodicalId":49544,"journal":{"name":"Seminars in Neurology","volume":" ","pages":"346-357"},"PeriodicalIF":2.2,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144976435","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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