WSC 2026 | Beyond atherosclerosis: uncommon carotid pathologies that are often overlooked by clinicians
Ivy Sebastian, MD, DM, Christian Medical College & Hospital, Ludhiana, India, discusses the non-atherosclerotic causes of carotid pathologies that are often overlooked by clinicians, highlighting the importance of looking beyond percentage stenosis and considering the vessel wall. Dr Sebastian notes that carotid web dissection and intraluminal thrombus are entities that are frequently missed, particularly in young patients, and emphasizes the need for neurologists to have a high threshold for recognition of these conditions. This interview took place at the 18th World Stroke Congress (WSC) in Seoul, Korea.
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Transcript
Yeah, I think the biggest diagnostic blind spot that we have and we’re looking at the carotids is that we have trained ourselves to look at the carotid arteries through the lense of just percentage stenosis and what we need to remember that the carotid is not just a pipe which is either narrow or not, it is a vessel wall. So we need to tend to look at the vessel wall as well so that we do not miss out on many of the other pathologies which are equally important and can cause stroke...
Yeah, I think the biggest diagnostic blind spot that we have and we’re looking at the carotids is that we have trained ourselves to look at the carotid arteries through the lense of just percentage stenosis and what we need to remember that the carotid is not just a pipe which is either narrow or not, it is a vessel wall. So we need to tend to look at the vessel wall as well so that we do not miss out on many of the other pathologies which are equally important and can cause stroke. So we tend to kind of look at the carotid artery through the concept of TOAST criteria, which is still the commonest criteria that we look at and the TOAST criteria mentions that more than 50% stenosis is what classifies it into large artery atherosclerosis. However, we have a lot of studies now which have shown that even less than 50% stenosis can be symptomatic carotids. In fact, studies across ESUS have shown that almost 20 to 30% of patients with non-stenotic carotids had unilateral hemispheric stroke. We don’t really have a consensus criteria on what to look for non-stenotic carotid, but Goyal et al have proposed some classifications to classify it into definite, probable and possible. Other pathologies, looking at the vessel wall, I would say one of the things that we tend to miss very often especially in young patients especially women is carotid web this is an entity that we don’t get to talk about much often. So if you have a patient with recurrent strokes with no explained causes I think we need to look carefully for carotid webs dissection is another scenario which we tend to miss. Again with young patients, especially a patient who’s had like probably an intense gym session or a chiropractic manipulation or even sometimes like a ride down the roller coaster and then presents with headache neck pain and then subsequently with stroke. And lastly intraluminal thrombus is another entity which is very rare but extremely dangerous with a high potential for embolic strokes as well. So these are some of the areas I think that as neurologists we need to kind of train ourselves and remind ourselves to have a high threshold for recognition.
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