Carotid web in patients with embolic stroke of undetermined source undergoing endovascular therapy for anterior circulation large vessel occlusion.

OBJECTIVE

Carotid web (CaW) is an emerging cause of embolic stroke of undetermined source (ESUS), yet its prevalence and clinical implications among ESUS patients presenting with anterior circulation intracranial large vessel occlusion (LVO) treated with endovascular therapy (EVT) remain unclear.

METHODS

We conducted a multicenter retrospective cohort study across three tertiary stroke centers, consecutively enrolling adults with acute ischemic stroke due to anterior circulation intracranial LVO (M1/M2) who underwent EVT between January 2017 and November 2025. ESUS was diagnosed after standardized etiologic workup. CaW was assessed on vascular imaging by two blinded neuroradiologists. Patients were stratified into CaW + and non-CaW ESUS groups. Baseline characteristics, procedural parameters, and 90-day functional outcomes assessed by the modified Rankin Scale (mRS) were compared.

RESULTS

Among 1170 EVT-treated anterior circulation LVO patients, 263 (22.5%) met ESUS criteria, of whom 40 (15.2%) had ipsilateral CaW. Patients with CaW were more frequently female (52.5% vs. 31.4%; P = 0.047), while baseline NIHSS, ASPECTS, occlusion distribution, reperfusion rates and hemorrhagic complications were similar. Favorable 90-day outcome was more frequent in the CaW-positive group (87.5% vs. 55.2%; P < 0.001). During a median follow-up of 18 months, recurrent ischemic stroke occurred in 28.0% (7/25) of medically treated CaW patients, whereas no recurrence was observed after carotid revascularization.

CONCLUSIONS

Ipsilateral CaW was identified in approximately 15% of EVT-treated ESUS patients with anterior circulation intracranial LVO and was associated with better functional outcomes without increased hemorrhagic risk. High recurrence under medical therapy warrants prospective evaluation of optimal secondary prevention strategies.