Carotid web : No longer a new kid in stroke risk

January 15, 2025 by dr s venkatesan

A carotid web is a shelf-like lesion along the posterior wall of the internal carotid artery bulb and an under-recognized cause of stroke in young individuals. Many studies suggest that patients with a carotid web have a high risk of recurrent stroke.

Various forms of carotid pathology

Image source : https://radiologyassistant.nl/neuroradiology/carotid-pathology/differentiating-carotid-pathology

In the famous Dutch study on ischemic stroke MR CLEAN, 30 patients had carotid web which is around 2% incidence. In this study 1 out of every 6 patients with a symptomatic carotid web had a recurrent stroke within 2 years, suggesting that medical management alone may not provide sufficient protection for patients with a carotid web.

Ref : Berkhemer OA, Fransen PSS, Beumer D, et al; MR CLEAN Investigators. A randomized trial for intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372:11–20

Histopathology & OCT

Choi PM AJNR Am J Neuroradiol. 2015 .Christopher R. Pasarikovski, Neurology: Clinical Practice 2019

How does it appear in carotid angiogram and in real time per-operative ?

Images : Chen H, Colasurdo M, Costa M, Nossek E, Kan P. Carotid webs: a review of pathophysiology, diagnostic findings, and treatment options. J Neurointerv Surg. 2024 Nov 22;16(12):1294-1298. doi: 10.1136/jnis-2023-021243. PMID: 38290814.

Management

The web can create a flow disturbance, potentiating local thrombus formation, which can embolize producing resulting in cerebral ischemia. Current treatment is with anti-thrombotics and/or anticoagulation .Lesser option is to alter the flow disturbance caused by the web (surgery or stent).

Final message

Cartoid web is no longer a diagnostic curiosity. Its worth looking forit an any young patients with cryptogenic stroke.

Reference

1.Rainer W.G., Cramer G.G., Newby J.P., et. al.: Fibromuscular hyperplasia of the carotid artery causing positional cerebral ischemia. Ann Surg 1968; 167: pp. 444-446.

2. Patel S.D., Otite F.O., Topiwala K., et. al.: Interventional compared with medical management of symptomatic carotid web: a systematic review. J Stroke Cerebrovasc Dis 2022; 31:

3.Gonzalez-Urquijo M, Vargas JF, Marchesini M, Marine L, Mertens R, Valdes F, Godoy-Santín J, Mellado P, Miranda H, Zoroquiaín JP, Sandoval P. Treatment of Symptomatic Carotid Webs. Ann Vasc Surg. 2025 Jan;110(Pt A):114-122. doi: 10.1016/j.avsg.2024.07.107. Epub 2024 Sep 27. PMID: 39343364.