Silent Threats: Asymptomatic Re-Thrombosis in Carotid Web and the Window for Preventive Intervention

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PURPOSE: Carotid web (CW) is an underrecognized cause of recurrent ischemic stroke in young patients with cryptogenic stroke, and its optimal management remains uncertain. This study aimed to determine the recurrence of ischemic events and the incidence of asymptomatic thrombus formation in CW, in order to optimize secondary prevention strategies. MATERIALS AND METHODS: We conducted a retrospective analysis of patients diagnosed with CW at a comprehensive stroke center in Spain between January 2021 and December 2024. CW was identified via computed tomography angiography or digital subtraction angiography. We assessed stroke recurrence, asymptomatic thrombus formation, and secondary prevention strategies. Early duplex sonography was systematically performed during hospitalization to detect in-hospital re-thrombosis. RESULTS: Among 23 patients with CW-related ischemic stroke, 2 (8.7%) experienced recurrent ipsilateral stroke. Notably 4 (17.4%) patients exhibited thrombus formation within the CW, 3 of them while still hospitalized, detected through early duplex sonography. These findings, which preceded any clinical recurrence, prompted timely anatomical correction via stenting or endarterectomy, with no further events observed. All patients with clinical or radiologic recurrence (n=6) underwent either carotid stenting (n=4) or endarterectomy (n=2), after which no further ischemic events were observed. CONCLUSION: CW carries a substantial risk of early thrombus formation and recurrent ischemic stroke. Routine early neurosonologic monitoring during hospitalization can detect in-hospital re-thrombosis and enable timely intervention with stenting or endarterectomy, which appears effective in preventing recurrence.

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