Delay in Carotid Web Diagnosis Remains Common and Associated With an Increased Risk of Stroke Recurrence

BACKGROUND: Carotid web is a rare and likely underrecognized cause of ischemic stroke, particularly in young patients. Given the high risk of recurrence, diagnostic delays may have serious consequences. This study aimed to assess the incidence and impact of delayed carotid web diagnosis after a first ischemic event. METHODS: We conducted a retrospective analysis using data from the French ongoing multicenter prospective CAROWEB (Carotid Web registry). We included patients with a first-ever ischemic stroke or transient ischemic attack in the anterior circulation, attributed to an ipsilateral carotid web with no other identifiable cause, between September 2013 and April 2023. Patients with missing data on the date of the first ischemic event or carotid web diagnosis, or with prior stroke history, were excluded. Participants were categorized into early diagnosis (≤30 days) and delayed diagnosis (>30 days) groups. Factors associated with diagnostic delay were investigated through univariable and multivariable analyses. Stroke recurrence was evaluated using Kaplan-Meier survival analysis. RESULTS: Of 280 patients in the registry, 225 met the inclusion criteria. A delayed diagnosis occurred in 57 patients (25.3%). Independent predictors of diagnostic delay included lower initial National Institutes of Health Stroke Scale score (odds ratio, 0.92; P =0.002), stroke occurring before 2019 (odds ratio, 0.19; P <0.001), and the absence of computed tomography angiography in the initial work-up (odds ratio, 0.20; P <0.001). Stroke recurrence was significantly higher in the delayed group (3.6 versus 0.38 per 100 patient-years). After adjusting for the National Institutes of Health Stroke Scale and year of stroke onset, delayed diagnosis was associated with a 5-fold increased risk of recurrence (aHR, 5.02; P =0.014). CONCLUSIONS: Delayed carotid web diagnosis remains common, especially in minor strokes, in the absence of early computed tomography angiography, and in events before 2019. Such delays are associated with a significantly increased risk of stroke recurrence, highlighting the need for early vascular imaging in ischemic stroke evaluation. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04431609.