Clinical analysis of 48 patients with carotid web diagnosed by digital subtraction angiography

To investigate the clinical characteristics, imaging features, relationship with ischemic stroke, treatment strategies, and follow-up outcomes of patients with carotid web (CaW) diagnosed by digital subtraction angiography (DSA), in order to improve the understanding and clinical management of CaW.

A retrospective analysis was conducted on the clinical data of 48 patients diagnosed with CaW by DSA in the Department of Cerebrovascular Diseases, Zhuhai People's Hospital from December 2021 to June 2025. Data included baseline characteristics, imaging findings, treatment methods, and follow-up results. All clinical outcomes (ischemic stroke, transient ischemic attack, recurrent ipsilateral ischemic event) were defined a priori according to the American Heart Association/American Stroke Association 2013 (stroke) and 2009 (tissue-based TIA) criteria, and follow-up imaging (carotid Doppler at 6 and 12 months, with brain MRI ± MRA/CTA when clinically indicated) was standardized across all patients.

The 48 patients aged from 28 to 83 years, with a mean age of (60.81 ± 11.58). There were 26 males (54.17%) and 22 females (45.83%). All lesions were located at the carotid bifurcation or the origin of the internal carotid artery. The typical DSA manifestation was a thin, linear or membranous filling defect originating from the vessel wall. Among the 48 patients, 13 had a history of smoking, 12 of alcohol consumption, 17 had hypertension, 18 had hyperlipidemia, 7 had diabetes mellitus, 2 had hyperhomocysteinemia, and 4 had hyperuricemia. There were 24 cases of left-sided CaW, 21 cases of right-sided CaW, and 3 cases of bilateral CaW. Subweb thrombus was present in 22 cases (45.83%). Acute ischemic stroke events occurred in 9 cases (18.75%). Treatment modalities included antiplatelet or anticoagulant therapy alone, endovascular interventional therapy, and surgical resection. Specifically, 34 patients received medication alone, 1 underwent emergency endovascular thrombectomy, 1 underwent carotid endarterectomy, 4 underwent carotid artery stenting, and 8 received no treatment. Patients were followed up for 3 to 12 months. One patient in the medication group experienced recurrence of ipsilateral cerebral infarction, while no ischemic events occurred in the remaining patients. "Recurrence" was defined as a new ipsilateral ischemic event occurring ≥24 h after the index event and meeting the AHA/ASA 2013 criteria. All patients completed the 12 month clinical follow-up; loss-to-follow-up was 0%.

In this retrospective, non-randomized cohort, the observed rate of recurrent ipsilateral ischemic events was numerically lower among patients who received active endovascular treatment (0/6) than among those who received medical therapy alone (1/34). However, given the very small number of patients who received active intervention, the short follow-up (3-12 months), and the non-randomized, indication-based treatment allocation, no causal inference can be drawn from these data regarding the efficacy of endovascular treatment in preventing stroke recurrence. The observed difference should be interpreted as hypothesis-generating only and requires confirmation in adequately powered prospective randomized controlled trials. Carotid web is an important risk factor for cryptogenic stroke across all age groups. DSA remains the diagnostic gold standard. For patients who have already experienced ischemic events or who have subweb thrombus, active endovascular treatment represents a potentially useful therapeutic option that warrants further evaluation.