Carotid web: an occult mechanism of embolic stroke

J Neurol Neurosurg Psychiatry. 2020 Dec;91(12):1283-1289. doi: 10.1136/jnnp-2020-323938. Epub 2020 Oct 1.


The carotid web is a proposed stroke mechanism that may underlie cryptogenic stroke, particularly in younger patients without vascular risk factors. The web appears as a shelf-like projection into the lumen of the proximal cervical internal carotid artery without evidence of calcification. It is pathologically defined as intimal fibromuscular dysplasia. Altered haemodynamics distal to the web cause flow stagnation and remote embolisation of fibrin-based clots. It is best demonstrated and diagnosed on CT angiography (CTA) of the neck because of its ability to resolve calcium and create multiplanar reconstructions. Although they can be readily visualised on CTA, carotid webs may be missed or misinterpreted because they do not typically cause haemodynamically significant stenosis and can mimic arterial dissection, non-calcified atherosclerotic plaque and intraluminal thrombus. Options for management include antiplatelet therapy, carotid endarterectomy and carotid artery stenting. Modern management strategies for cryptogenic stroke include long-term cardiac monitoring, further investigation for structural cardiac disease and a diagnostic workup for arterial hypercoagulability, however, these strategies are not likely to capture the possibility of a carotid web. Carotid webs should be suspected in a young patient presenting with recurrent unihemispheric strokes particularly when conventional vascular risk factors are not present.

Keywords: cerebrovascular disease; stroke; vascular surgery.

Publication types

  • Review

MeSH terms

  • Age of Onset
  • Anticoagulants / therapeutic use
  • Carotid Artery Diseases / complications
  • Carotid Artery Diseases / diagnostic imaging*
  • Carotid Artery Diseases / pathology
  • Carotid Artery Diseases / therapy
  • Carotid Artery, Internal / diagnostic imaging*
  • Carotid Artery, Internal / pathology
  • Computed Tomography Angiography
  • Endarterectomy, Carotid
  • Endovascular Procedures
  • Fibromuscular Dysplasia / complications
  • Fibromuscular Dysplasia / diagnostic imaging*
  • Fibromuscular Dysplasia / pathology
  • Fibromuscular Dysplasia / therapy
  • Humans
  • Ischemic Stroke / etiology*
  • Platelet Aggregation Inhibitors / therapeutic use
  • Stents
  • Tunica Intima / diagnostic imaging*
  • Tunica Intima / pathology


  • Anticoagulants
  • Platelet Aggregation Inhibitors