Clinical features and surgical outcomes in patients with symptomatic carotid artery webs

Symptomatic carotid web (CW) is an underrecognized cause of stroke in young patients, with treatment approaches still debated. We compare clinical features and surgical outcomes in patients with pathologically confirmed symptomatic CW.

We conducted a case-control study of patients with pathologically confirmed symptomatic CW, treated at Montefiore-Einstein Medical Center between January 1, 2017, and August 1, 2024. From a total of 7019 cases of acute ischemic stroke (AIS) including 415 carotid endarterectomies (CEAs), we identified patients presenting with symptomatic CW based on standardized radiographic and clinical criteria. Clinical, demographic, imaging, and outcome data were extracted via automated tools and manual review, and carotid interventions were adjudicated by a vascular neurologist and vascular surgeon. A multivariable logistic regression model evaluated associations between clinical variables and symptomatic CW. Additionally, a random forest classification model was used to evaluate the importance of relevant clinical variables in predicting symptomatic CW.

Over the 7.5-year period, 64 cases of symptomatic CW were identified, accounting for 0.91% of all AIS cases. Patients with symptomatic CW were significantly younger (mean age, 54.52 vs 68.56 years; P < .001) and more likely to be female (67.7% vs 49.8%; P = .036) compared with all patients with AIS. Of these, 56 (87.5%) underwent carotid endarterectomy, representing 13.5% of all CEAs. Compared with other CEA patients, those with symptomatic CW were more likely to be younger than 55 years of age (50.0% vs 7%; P < .001), female (66.7% vs 40.7%; P = .001), and had fewer comorbidities, including lower rates of hypertension, diabetes, smoking, congestive heart failure, coronary disease, and chronic obstructive pulmonary disease. In adjusted regression, age under 55 years, female sex, and absence of diabetes or smoking were independently associated with symptomatic CW. In the random forest model, age, sex, smoking history, hypertension, and diabetes were the most important predictors of symptomatic CW. Surgical outcomes were favorable, with no perioperative or 30-day strokes and no recurrent ipsilateral events at a mean follow-up of 41 months. Only 20% of CWs caused hemodynamically significant stenosis.

Symptomatic CW is an uncommon but distinct cause of AIS, particularly in younger, female patients with few vascular risk factors. Although often lacking significant stenosis, CWs were frequently treated with carotid endarterectomy, which was safe and associated with excellent long-term outcomes.