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Carotid Web

Summary

  • Carotid web is a rare, non-atherosclerotic cause of ischaemic stroke
  • Characterised by a shelf-like projection in the lumen of the internal carotid artery
  • Diagnosis often challenging, requiring high-resolution imaging techniques1

Pathophysiology

  • Believed to be a variant of fibromuscular dysplasia
  • Abnormal accumulation of fibrous tissue in the tunica intima of the carotid artery
  • May act as a nidus for thrombus formation, leading to embolic stroke
  • Typically located at the posterior wall of the carotid bulb or proximal internal carotid artery

Demographics

  • More common in middle-aged adults (40-60 years)
  • Higher prevalence in women
  • Increased incidence in African American population
  • Often associated with cryptogenic stroke in younger patients without traditional risk factors

Diagnosis

  • Clinical presentation:
    • Recurrent ischaemic strokes or transient ischaemic attacks
    • Often misdiagnosed as cryptogenic stroke
  • Physical examination:
    • Usually unremarkable
    • No specific findings associated with carotid web

Imaging

  • Conventional angiography:
    • Gold standard for diagnosis
    • Appears as a thin, linear filling defect on the posterior wall of the carotid bulb
  • CT angiography (CTA):
    • Modality of choice
    • Axial images show a thin shelf-like intraluminal filling defect on the posterior wall of the bulb
    • Sagittal reconstructions show a thin septum/diaphragm projecting into the lumen, sometimes with a small pouch of stagnant contrast distally
  • MR angiography (MRA):
    • Less sensitive than CTA
    • May show focal narrowing or filling defect in the carotid bulb
  • Ultrasound:
    • Limited utility due to low sensitivity
    • May show a small, echogenic projection in the carotid lumen

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  • Incidental finding of a linear filling defect along the posterior wall of the internal carotid artery.

Treatment

  • Antiplatelet therapy; carotid endarterectomy or stenting for recurrent symptomatic stroke

Differential diagnosis

Differential Diagnosis Differentiating Feature
Atherosclerotic plaque Carotid web appears as a thin, shelf-like filling defect on angiography, while atherosclerotic plaque is typically more irregular and eccentric
Fibromuscular dysplasia Carotid web is typically located at the carotid bulb, while fibromuscular dysplasia affects more distal segments of the carotid artery
Carotid dissection Carotid web is a static lesion, while dissection may show a dynamic intimal flap or double lumen on imaging
Carotid artery spasm Carotid web is a persistent finding, whereas spasm is transient and can be relieved with vasodilators
Intraluminal thrombus Carotid web has a characteristic shelf-like appearance, while thrombus typically appears as a filling defect without the shelf-like morphology
Carotid body tumour Carotid web does not enhance on contrast imaging, while carotid body tumours typically show intense enhancement
Arteritis Carotid web is localised, while arteritis often involves longer segments of the vessel and may show wall thickening
Pseudoaneurysm Carotid web does not expand the vessel lumen, unlike a pseudoaneurysm which appears as an outpouching

  1. Rivoire et al. Carotid web: Pathophysiology, diagnostic, and therapeutic options. A narrative review. 2025. Vascular medicine (London, England) - Open in new tab. ↩