A Bilateral Carotid Web Presenting as Recurrent Transient Ischemic Attacks With Negative Initial Stroke Imaging: A Case Report

Carotid webs (CWs) are an increasingly recognized cause of ischemic stroke and transient ischemic attacks (TIAs), particularly in patients without an alternative clearly identified etiology, although they likely remain underdiagnosed because of their subtle radiographic appearance and the absence of significant carotid stenosis. The lesion is considered an intimal variant of fibromuscular dysplasia that may promote local blood stasis, thrombus formation, and distal cerebral embolization. We present the case of a 59-year-old woman with recurrent transient neurological deficits and initially negative stroke imaging who was ultimately diagnosed with a bilateral CW. Computed tomography angiography demonstrated bilateral thin linear filling defects at the carotid bulbs, more prominent on the left side, consistent with a CW. Magnetic resonance imaging performed using a stroke protocol showed no evidence of acute ischemic or hemorrhagic stroke. Electroencephalography was normal, and no definitive cardioembolic source was identified. Subsequent digital subtraction angiography confirmed abnormal flow dynamics involving both carotid bulbs. Balloon occlusion testing demonstrated insufficient collateral circulation, supporting the hemodynamic significance of the lesion. Given the recurrent ischemic symptoms and angiographic findings, the patient underwent endovascular carotid reconstruction with angioplasty and placement of a left internal carotid artery stent. Post-procedural angiography demonstrated improved carotid flow dynamics without complications. The patient remained neurologically stable during follow-up without recurrent cerebrovascular events. This case highlights the importance of considering CWs in patients with recurrent cryptogenic TIAs or stroke-like symptoms despite negative initial neuroimaging. Early recognition through dedicated vascular imaging may facilitate timely intervention and potentially reduce recurrent cerebrovascular events.