ABSTRACT NUMBER: ESOC2026A2185 RECURRENT LARGE VESSEL OCCLUSION IN CAROTID WEB AND POSSIBLE ANTIPHOSPHOLIPID SYNDROME: IMPLICATIONS FOR EARLY ENDOVASCULAR TREATMENT

Abstract Background and aims Carotid web (CaW) is an underrecognized non-atherosclerotic cause of embolic stroke with high recurrence risk. Optimal management remains debated, especially in patients with concomitant prothrombotic conditions such as antiphospholipid syndrome (APS). Methods We report a patient with recurrent right hemispheric ischemic strokes associated with CaW and suspected APS, focusing on diagnostic findings, antithrombotic strategies, endovascular management, and outcomes. Multimodal imaging, thrombophilia screening, and serial neurovascular assessments were performed. Results A 66-year-old man developed recurrent right middle cerebral artery occlusions over six weeks. Initial treatment included intravenous thrombolysis and repeated mechanical thrombectomy. Despite escalation from dual antiplatelet therapy to intensified antiplatelet regimens and finally to full anticoagulation with warfarin (INR 3.5–4.1), ischemic recurrences persisted. Imaging consistently demonstrated a carotid web at the right internal carotid artery bulb with local thrombus formation and features of carotid dissection. Thrombophilia screening revealed lupus anticoagulant and high-titer anticardiolipin IgG, suggesting APS. After a third large vessel occlusion, carotid artery stenting fully covering the web was performed. No procedural complications occurred, and no further ischemic events were observed during three-month follow-up under combined antithrombotic therapy. Conclusions This case illustrates the marked thromboembolic instability of carotid web, even under aggressive medical therapy and in the presence of prothrombotic conditions. Early definitive treatment with carotid stenting or endarterectomy should be strongly considered after the first ischemic event, rather than delaying intervention despite medical therapy escalation. Conflict of interest Nothing to disclose