A new study confirms the high risk of recurrent stroke in patients with a symptomatic carotid web, suggesting that medical management alone may not provide adequate protection, researchers say. "The 2-year recurrent stroke risk was 17%, which is much higher than would be expected (normally 1-2% per year after stroke)," Dr. Jonathan Coutinho of Amsterdam University Medical Center, in the Netherlands, told Reuters Health by email. "The high recurrence rate we observed in patients with a symptomatic web is worrisome," Dr. Coutinho said. A carotid web is a shelf-like fibrous band along the posterior wall of the internal carotid artery bulb and an "underrecognized cause of young stroke," he and his colleagues note in JAMA Neurology. Several studies have suggested that patients with a symptomatic carotid web are at high risk of recurrent stroke, but the true recurrent stroke risk remains unclear. To investigate, the researchers studied more than 3,400 patients (median age, 77 years; 53% men) with large-vessel-occlusion stroke of the anterior circulation, 30 (0.9%) of whom had a carotid web ipsilateral to the side of the index stroke. Patients with a carotid web were significantly younger (median age, 57 vs. 66 years) and more often women (73% vs. 40%) than patients without a carotid web. All but two patients with a carotid web received medical management after the index stroke (23 with antiplatelet therapy and five with anticoagulant therapy). During two years of follow-up, five of the 30 patients with a carotid web (17%) suffered a recurrent stroke compared to five of 168 patients (3%) without a carotid web (adjusted hazard ratio, 4.9; 95% confidence interval, 1.4 to 18.1). "While we cannot determine from our study what the optimal treatment strategy is for patients with a symptomatic carotid web, we think most colleagues will agree that the 17% recurrent stroke risk we observed in only 2 years is much too high," Dr. Coutinho told Reuters Health. "Since most of the patients in our study were managed with standard antiplatelet therapy, our conclusion is that antiplatelets alone provide insufficient protection." "Other treatment possibilities that may be considered are anticoagulation, stenting of the web or surgical removal of the web. However, since we did not study these treatment options, we cannot make any conclusions on whether these therapies are indeed more effective than antiplatelet therapy," Dr. Coutinho said. "At the very least, clinicians should follow-up patients with a symptomatic carotid web closely, and if a recurrent stroke/TIA occurs consider (and discuss with the patient) alternative treatment options," he added. Dr. Daniel G. Hackam of the division of clinical pharmacology at Western University, in London, Canada, said this is "an interesting study, suggesting a need for surgical or endovascular intervention in patients with a symptomatic carotid web." Dr. Hackam, who studies vascular health, said the results are in line with a recent systematic review on the subject. Echoing the authors, Dr. Hackam said, "The high rate of recurrence suggests medical therapy is not enough to treat symptomatic carotid webs, similar to how we treat symptomatic carotid stenosis (with revascularization by either surgery or stenting). All such patients should of course also receive optimal medical therapy consisting of a statin, antiplatelet and antihypertensive therapy (if indicated)." —Megan Brooks Source
