Carotid Web Increases Recurrent Stroke Risk

Carotid web, a shelf-like lesion along the posterior wall of the internal carotid artery bulb, is associated with an increased risk for recurrent stroke within 2 years of the index stroke, suggesting such patients may require more intensive secondary prevention measures, according to study results published in JAMA Neurology.

Previous studies indicated that symptomatic carotid webs are found in 9% to 37% of patients younger than 60 years with cryptogenic stroke, and that this carotid protrusion is associated with a 10- to 20-fold increased risk for recurrent stroke, but high-quality data are lacking.

The objective of the current study was to determine the 2-year risk for recurrent stroke in patients with a symptomatic carotid web.

Using data from the MR CLEAN trial (from 2010 to 2014) and MR CLEAN Registry (from 2014 to 2017), nationwide prospective multicenter studies on endovascular treatment, study researchers identified 3439 consecutive patients with large vessel occlusion stroke. Presence of carotid web ipsilateral to the index stroke was determined by 2 neuroradiologists who re-evaluated CT-angiography images.

A total of 30 patients had a carotid web ipsilateral to the index stroke. Study researchers compared these patients with 168 patients without a carotid web who enrolled in the MR CLEAN follow-up trial.

The primary outcome was recurrent stroke within 2 years of the index stroke, comparing rates for patients with and without a carotid web.

Compared with patients without a carotid web, patients with a carotid web were younger (median age, 57 years vs 66 years, respectively; P =.01) and were more likely to be women (women, 73% vs 40%, respectively; P =.001).

Most patients (28 of 30 patients; 93%) received medical treatment following the index stroke, including 23 with antiplatelet therapy and 5 with anticoagulant therapy.

Over the course of a 2-year follow-up period, 5 of 30 patients (17%) with a carotid web had a recurrent stroke, compared with 5 of 168 patients (3%) without a carotid web (adjusted hazard ratio, 4.9; 95% CI, 1.4-18.1).

Type and location of the recurrent stroke were determined in 4 of 5 patients with a carotid web, and all 4 cases were in the same vascular territory as the carotid web.

Restricting the analysis to those with recurrent ischemic stroke ipsilateral to the index stroke showed an 8-fold increased risk for recurrent stroke in patients with ipsilateral carotid web, compared with those without a carotid web (adjusted hazard ratio, 8.1; 95% CI, 1.4-46.8).

The study had several limitations, including missing follow-up data, lack of standardized secondary measures, limited number of patients with a carotid web, and differences between the study populations in the two included studies.

“Our data suggest that medical management alone may not provide sufficient protection for recurrent stroke. Prospective studies on targeted secondary prevention measures for patients with a CW [carotid web] are warranted,” concluded the study researchers.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

Guglielmi V, Compagne KCJ, Sarrami AH, et al. Assessment of recurrent stroke risk in patients with a carotid web. JAMA Neurol. Published online May 10, 2021. doi:10.1001/jamaneurol.2021.1101