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Sebastian outlines a tiered carotid imaging strategy and the CTA findings pointing to dissection, vasculitis, or intraluminal thrombus.
Ivy Sebastian, MD, DM, a neurologist at Christian Medical College and Hospital in Ludhiana, India, said recognizing non-atherosclerotic carotid disease on vascular imaging can shift management away from standard carotid stenosis algorithms.
Speaking with HCPLive at the 2026 World Stroke Congress in Seoul, Republic of Korea, Sebastian addressed when to escalate beyond first-line imaging and which lesions call for a different treatment strategy.¹ She also cautioned advanced imaging is revealing more biologically active carotid lesions, not all of which carry clinical significance.
“We do not need to do advanced vessel wall imaging in every patient,” said Sebastian. “The first step would be to just do a CT [angiography] in a patient with stroke.”
According to Sebastian, high-quality CT angiography (CTA) or magnetic resonance angiography (MRA) is often the appropriate first imaging step in patients with stroke, suspected stroke, or transient ischemic attack (TIA). In many settings, carotid Doppler ultrasound may be the only first-line modality available. Advanced techniques, including MRI vessel wall imaging, can supplement these initial studies but are not required for every patient.
Escalation is warranted when initial imaging reveals a clinically suspicious finding, such as a high-risk, vulnerable, or unstable plaque. Sebastian said the decision should also weigh the full clinical presentation and whether additional imaging would resolve an open diagnostic question. She described a tiered approach as especially important in resource-limited settings, including her own.
Pairing careful clinical phenotyping with high-quality initial vascular imaging allows clinicians to decide which lesions merit further workup. Sebastian said that without this discipline, clinicians risk overdiagnosing biologically interesting lesions lacking clinical relevance. The downstream consequence can be exposing patients to interventions they do not need.
Sebastian identified intraluminal thrombus as a key example where a standard stenosis pathway may be inappropriate. The lesion appears as an elongated thrombus attached to the carotid wall with a free-floating tip. It is uncommon but highly thrombogenic, particularly early in its course, and patients can present with recurrent strokes or TIA-like episodes.
For a stenotic atherosclerotic lesion, revascularization is often among the first options considered. In intraluminal thrombus, the same approach carries added risk.
“Jumping in with the revascularization process in an intraluminal thrombus would actually be more dangerous because here we are at the risk of manipulating the thrombus, and it could actually further cause more embolization,” Sebastian said.
She pointed to the 2023 European Society for Vascular Surgery (ESVS) guidelines, which added a dedicated section on free-floating thrombus.1 The recommended approach begins with anticoagulation to stabilize the thrombus, with revascularization reserved for patients who continue to have recurrent symptoms despite anticoagulation.
Imaging features can also flag dissection. Sebastian said a mural hematoma or intimal flap on CTA should prompt consideration of carotid dissection, which may follow mechanical trauma or relate to an underlying inflammatory process or fibromuscular dysplasia, and is more common in younger patients.
Concentric luminal narrowing is another signal. Eccentric narrowing is the typical pattern in atherosclerotic disease, and Sebastian said a concentric pattern should push clinicians to evaluate for vasculitis or fibromuscular dysplasia.
The 2023 ESVS guidelines explicitly exclude non-atherosclerotic conditions, including fibromuscular dysplasia, dissection, and arteritis, from their scope.1 For these patients, accurate etiologic classification at the imaging stage determines which management pathway applies.
Watch part 1 of our interview with Sebastian here: Carotid Disease Beyond Stenosis, With Ivy Anne Sebastian, MD.2
Editor’s note: Sebastian has no reported disclosures.
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