What is the treatment for a carotid web?

Treatment of Carotid Web

For patients with symptomatic carotid web, first-line treatment is antiplatelet therapy, with carotid revascularization (stenting or endarterectomy) recommended for those with recurrent strokes despite medical management. 1

Understanding Carotid Web

• Carotid web is a thin, circumferential shelf-like filling defect that arises from the posterior wall of the internal carotid artery bulb, visible on CTA or carotid angiography 1
• Pathologically, it is considered a variant of fibromuscular dysplasia that can be classified as focal or multifocal 1
• It is a known cause of ischemic stroke in younger patients (under 65 years), detected in up to 9.5% of patients under 65 with anterior circulation stroke of unknown cause 1
• Platelet deposition can occur in the corrugations of carotid web, forming a nidus for blood flow stagnation and thromboembolism 1

Medical Management

First-Line Treatment

• Antiplatelet therapy is recommended for patients with carotid web in the distribution of ischemic stroke and TIA without other attributable causes of stroke 1
• Options include:
  • Aspirin 81-325 mg daily 1
  • Clopidogrel 75 mg daily 1
  • Aspirin + dipyridamole 25/200 mg daily 1

Considerations for Medical Management

• Medical management with antithrombotic therapy is the first-line treatment, though it's not established whether single antiplatelet therapy, short-term dual antiplatelet therapy, or anticoagulant therapy is superior 1
• The recurrence rate of cerebral ischemia in patients treated with medical therapy alone ranges from 26.8% to 56% over follow-up periods of 2-55 months 2, 3
• In systematic reviews, approximately 32% of patients with carotid web managed medically experienced recurrent ischemic stroke ipsilateral to the carotid web 3

Interventional Management

Indications for Revascularization

• Carotid stenting or carotid endarterectomy (CEA) may be considered in patients with carotid web in the distribution of ischemic stroke refractory to medical management, with no other attributable cause of stroke despite comprehensive workup 1
• Interventional treatment should be considered when patients have recurrent strokes despite optimal medical therapy 2

Efficacy and Safety of Revascularization

• Carotid revascularization (stenting or endarterectomy) is associated with significantly lower risk of recurrent ischemic stroke compared to medical management (relative risk 0.11,95% CI 0.06-0.28) 3
• Both carotid endarterectomy and carotid artery stenting appear equally effective in reducing recurrent stroke risk 3
• Periprocedural complications are rare, with studies reporting major periprocedural complications in only 0.5% of cases and no recurrent ischemic events over follow-up periods of 3-60 months 2

Treatment Algorithm

1. Initial Diagnosis:

   • Confirm carotid web diagnosis using CT angiography, MR angiography, or invasive angiography with contrast 4
   • Rule out other causes of stroke 1

2. First-Line Treatment:

   • Begin antiplatelet therapy (aspirin 81-325 mg daily or clopidogrel 75 mg daily) 1

3. Monitoring and Follow-up:

   • Regular clinical and imaging follow-up to assess for recurrent symptoms or stroke 2

4. For Recurrent Events:

   • If patient experiences recurrent ischemic events despite antiplatelet therapy, consider carotid revascularization 1, 2
   • Options include carotid endarterectomy or carotid artery stenting, both with similar efficacy 3

Special Considerations

• Carotid webs are often missed on initial imaging, with studies showing up to 40% not identified by initial radiology interpretation 5
• Carotid web predominantly affects younger patients (median age 49.5 years) without traditional stroke risk factors 2
• Women (61.7%) and Black patients (76.6%) appear to be more frequently affected 2, 6
• Thrombus adherent to carotid web may be detected on initial imaging in approximately 16.2% of cases 2

Knowledge Gaps and Limitations

• The optimal management of symptomatic carotid web remains uncertain due to lack of large randomized trials 3
• The natural history of carotid web under medical management is not fully understood 3
• Current evidence comes primarily from small, heterogeneous cohorts and case series 3
• Future prospective research comparing medical management with interventional management is needed 1