Introduction/Purpose Carotid webs are an underrecognized cause of embolic ischemic stroke, typically presenting in younger patients and often identified by their characteristic shelf‐like morphology and minimal associated stenosis on angiography. However, non‐calcified atherosclerotic plaques can mimic this appearance, leading to diagnostic uncertainty. We report a case of presumed carotid web based on classic imaging features that was found to be an atherosclerotic plaque on histopathologic examination after carotid endarterectomy (CEA). Materials/Methods Single‐patient case report. Results A 58‐year‐old man with hypertension, hyperlipidemia, type II diabetes, and a 10‐pack‐year smoking history presented with acute left hemiparesis, hemispatial neglect, and dysarthria. Last known normal was eight hours before arrival; NIH Stroke Scale score was 18. Non‐contrast head CT demonstrated right M1 segment hyperdensity, mild right insular region hypodensity, and no acute hemorrhage. CT angiography revealed right M1 occlusion. The patient underwent mechanical thrombectomy with complete reperfusion (TICI 3). Digital subtraction angiography (DSA) confirmed a proximal right M1 occlusion and revealed an intraluminal, shelf‐like filling defect arising from the posterior wall of the right internal carotid artery (ICA) at the level of the carotid bulb, with contrast stasis posterior to the lesion, suspicious for carotid web. In retrospect, the abnormality was also visible on initial CTA, with only 30% luminal stenosis by NASCET criteria.Brain MRI demonstrated infarcts in the right MCA territory, specifically involving the right insula, basal ganglia, and frontal and parietal lobes, with no chronic infarcts in other vascular territories. Routine coagulation panels were normal, LDL was 60 mg/dL, HbA1c was 11.0%, transthoracic echocardiography was unremarkable, and non‐invasive ambulatory cardiac monitor detected no episodes of atrial fibrillation or atrial tachycardia within two weeks of recording. CT of the chest was negative for malignancy. Given the patient's relatively young age, the presence of an embolic‐appearing ischemic stroke without an obvious cardioembolic source or underlying hypercoagulable state, and the classic shelf‐like morphology with minimal stenosis, artery‐to‐artery embolization from carotid web was considered the most likely stroke etiology. The patient was discharged to acute inpatient rehabilitation. One month later, he underwent elective right CEA for secondary stroke prevention. Intraoperatively, the suspected web was visualized and resected en bloc. Histopathological analysis revealed the lesion to be a non‐calcified atherosclerotic plaque rather than a fibrous intimal web.Following this unexpected diagnosis, the patient's medical management was adjusted to emphasize aggressive atherosclerosis risk reduction. At one‐year follow‐up, the patient remained neurologically intact with no recurrent cerebrovascular events. He was adherent to prescribed medications with improved glycemic control and LDL cholesterol < 70 mg/dL. Conclusion This case illustrates that even lesions with classic radiographic features of carotid webs may represent non‐calcified atherosclerotic plaques, particularly in patients with vascular risk factors. As imaging alone may be insufficient for definitive diagnosis, CEA not only restores ICA patency but also provides diagnostic tissue, enabling accurate etiologic classification and appropriate long‐term secondary stroke prevention. In cases of embolic stroke with equivocal imaging findings, particularly when the clinical context raises concern for both carotid web and atherosclerosis, histopathologic confirmation can be essential.
Grin et al. (Sat,) studied this question.