Introduction. Carotid web (CaW), a focal intimal dysplasia, is a potential cause of embolic ischemic stroke (IS). The optimal therapeutic approach for symptomatic CaW remains unclear.

Methodology. Since January 2016, patients hospitalized for IS with an ipsilateral CaW, identified during etiological workup, are prospectively included in this ongoing single-center observational cohort study.

Results. Until April 2024, 32 patients (59% men; mean age 48 ± 7.5 years; mean NIHSS score 8 ± 6) were included. Seven patients (22%) had a history of prior IS. Thrombolysis and/or thrombectomy were performed in 15 patients (47%). During follow-up, recurrent IS occurred in 6 patients (19%), while on antiplatelet therapy (APT), with a median recurrence time of 39 days (IQR 8-144).

Etiological workup identified CaW on CT angiography in 30 patients (94%) and on arteriography in 17 patients (53%). CaW was suspected on ultrasonography in 26 patients (81%) and confirmed with a second imaging modality. CaW was identified as the primary etiological diagnosis in 29 patients. Alternative diagnoses in 3 patients included atrial fibrillation (n=1), patent foramen ovale (n=1) and inherited thrombophilia (protein S deficiency) associated with a suspected right-to-left pulmonary shunt on transesophageal echocardiography (n=1).

Among the 29 patients with symptomatic CaW, anticoagulation was prescribed in 21 cases (72%). Antiplatelet therapy (APT) was prescribed in 8 patients (28%), primarily due to hemorrhagic transformation in 7 of them.

Carotid endarterectomy (26 patients) or angioplasty with stent placement (3 patients) was performed within a median of 28 days (IQR 14–84) with no major complications (2 spontaneously resolving laryngeal edema). Histopathological analysis of 19 endarterectomy specimens revealed associated thrombus in 5 cases (26%). Postoperatively, all patients were prescribed APT. No ischemic recurrence or death was reported during a mean follow-up of 24 ± 20 months.

Conclusion. Medical management alone for symptomatic CaW was associated with IS recurrence. Combined interventional approach effectively prevented cerebrovascular events. Further randomized studies are needed to determine the optimal therapeutic approach, particularly the preferred revascularization strategy.