Symptomatic Carotid Web Requires Aggressive Intervention
Clayton J. Brinster, James O'Leary, Aaron Hayson, Andrew Steven, Gabriel Vidal, G. Ross Parkerson, Hernan Bazan, Charles Leithead, Samuel R Money, W.C. Sternbergh, III
Ochsner Health, New Orleans, LA
BACKGROUND:
Carotid web (CaWeb) is a rare form of fibromuscular dysplasia that can produce embolic stroke. Misdiagnosis of symptomatic CaWeb as “cryptogenic stroke” or “embolic stroke of unknown source” is common and can lead to recurrent, catastrophic neurologic events. Reports of CaWeb in the literature are scarce, and their natural history is poorly understood. Appropriate management remains controversial.
METHODS:
CaWeb was defined as a single, shelf-like, linear projection in the posterolateral carotid bulb causing a filling defect on computed tomography angiography (CTA) or cerebral angiography (Figure 1). Cases of symptomatic CaWeb at a single institution with a high-volume stroke center were identified through collaborative evaluation by vascular neurologists and vascular surgeons.
RESULTS:
Fifty-two patients with symptomatic CaWeb were identified during a six-year period (2016-2022). Average age was 49 years (range, 29-73), 35/52 (67%) were African American, and 18/52 (35%) were African American women under age 50. Patients initially presented with stroke (47/52, 90%) or TIA (5/52, 10%). Stenosis was <50% in 50/52 (96%) based on NASCET criteria, and 0/52 (0%) CaWebs were identified with carotid duplex. Definitive diagnosis was made by CTA examined in multiple planes or cerebral angiography examined in a lateral projection to adequately assess the posterolateral carotid bulb, where 52/52 (100%) of CaWebs were seen. Early in our institutional experience, six patients (12%) with symptomatic CaWeb were managed initially with dual antiplatelet and statin therapy or systemic anticoagulation - all suffered ipsilateral recurrent stroke at an average interval of 23 months (range 1-66), and three were left with permanent deficits. Definitive treatment included carotid endarterectomy in 27/50 (54%) or carotid stenting in 23/50 (46%). Two strokes were irrecoverable, and intervention was deferred. Web-associated thrombus was observed in 16/50 (32%) on angiography or grossly upon carotid exploration (Figure 2). Average interval from initial stroke to intervention was 39 days. After an average follow-up of 26 months, there was no reported post-intervention stroke or mortality.
CONCLUSIONS:
To our knowledge, this is the largest single-institution analysis of symptomatic CaWeb yet reported. Our series demonstrates that carotid duplex is inadequate for diagnosis, and that medical management is unacceptable for symptomatic CaWeb. Recurrent stroke occurred in all patients managed early in our experience with medical therapy alone. We have since adopted an aggressive interventional approach in cases of symptomatic CaWeb, with no postoperative stroke reported over an average follow-up of 26 months. In younger patients presenting with cryptogenic stroke, especially African American women, detailed review of lateral cerebral angiography or multi-planar, fine-cut CTA images is required to accurately rule out or diagnose CaWeb and avoid recurrent neurologic events. 
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