To describe an under-recognized, rare cause of stroke in the young.

Carotid web is a non-atheromatous strand of tissue protruding into the lumen of the internal carotid artery (ICA) distal to its origin. Carotid web may cause blood stagnation distal to the lesion leading to artery-to-artery embolization with high risk for recurrent ischemic strokes. It is unclear if carotid webs are congenital or not, as asymptomatic webs often go undiagnosed; their estimated incidence is unclear. Carotid webs are more frequently seen in cryptogenic stroke in young patients (younger than 55 years) as compared to non-stroke controls.

We report a case of a 44-year-old African-American woman who presented with acute onset left face and arm weakness (NIH stroke scale of 3). She had an upper respiratory tract infection the week prior and had been forcefully sneezing and coughing. Head CT scan showed an area of hypodensity in the right putamen and CT angiography (CTA) raised suspicion for dissection of the right ICA versus a carotid web. Magnetic resonance (MR) imaging of the brain and MR angiogram dissection protocol showed a subacute right putaminal infarct with a non-occlusive T-shaped thrombus at the right middle cerebral artery bifurcation and a right ICA web approximately 4mm from the origin.

It was suspected that a forceful cough and/or sneeze may have dislodged a thrombus from the carotid web distally. She was treated with oral anticoagulation and remains stable with eventual plans for endovascular stenting of the carotid web.

Cervical ICA web is a rare cause of ischemic stroke and should be considered in the differential diagnosis of cryptogenic stroke in young adults. Further research is needed to determine the best medical and/or endovascular treatment plan to prevent ischemic stroke recurrence.