ISC 2026 | Carotid web morphology over time and the associated stroke risk: a longitudinal imaging study

Regarding how the webs are evolving over time, we found in our study that these lesions are mostly stable over time and over a median follow-up time of 16.5 months, only 8 out of the 83 patients in our cohort with multiple CTAs showed a considerable change in any of their morphologic features. And that was often presumed to be due to a superimposed thrombus. And so, the absence of morphologic changes in carotid webs may be helpful in diagnosis and may help improve the diagnostic confidence in distinguishing carotid webs from their mimics, such as atherosclerotic plaques and also dissections. And none of these patients with a considerable change in our cohort had a recurrent event due to carotid web. So we can’t comment on that part in terms of risk of recurrence in those who had a considerable change. And the only morphologic feature that we found to be associated with the risk of a stroke was carotid web length. And one may say, so if we have a web that is increasing in size, especially in length, we should be concerned. Well, maybe, but this study was not powered enough to detect such an effect and to kind of support this hypothesis. And this needs future research to investigate that further. So we categorized our patients into symptomatic webs versus asymptomatic ones. And symptomatic webs were the ones who had a stroke or TIA attributed to carotid web at the time we identified those patients. And none of the patients who had asymptomatic carotid webs, meaning incidentally found during other workups, had a recurrent event. So the recurrence rate in those patients was zero, but three out of 28 patients with a symptomatic carotid web had a recurrent event due to carotid web. And in terms of the, because patients had different follow-up times, the risk of recurrence due to carotid web was about 6% per 100 patient-years versus zero in the asymptomatic group. And thus, we don’t recommend any intervention for the asymptomatic carotid web based on the current data. Regarding the risk of recurrence in the symptomatic carotid webs and how we should approach those patients in terms of secondary stroke prevention, we don’t have clinical trial data to come up with a firm recommendation for sure. But as we observed in our cohort and in line with previous literature, the risk of recurrence in these patients is pretty high. And the observational data showed that carotid artery interventions, such as carotid artery stenting or endarterectomy, were associated with zero risk of recurrence. But on the other hand, using antithrombotic treatment was associated with recurrent events in these patients. And in our discussion between our stroke physicians at Penn, physicians were more inclined nowadays to use carotid artery intervention in those with symptomatic carotid webs. And in our cohort, those three patients who had a recurrent event, one was on single antiplatelet, one on DAPT, and the other was on anticoagulant. So I think with the current literature, we can say it might be reasonable to go with carotid artery intervention for those who had a symptomatic carotid webs, but not asymptomatic ones.

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