Useless. You assessed something but gave no solution to completely prevent that stroke risk.
Assessment of Recurrent Stroke Risk in Patients With a Carotid Web
Question What is the 2-year risk of recurrent stroke in patients with a symptomatic carotid web (CW)?
Findings In this cohort study among 3439 patients with large vessel occlusion stroke, during 2 years’ follow-up, 17% of patients with an ipsilateral CW had a recurrent stroke compared with 3% of patients without CW. Ninety-three percent of patients with a CW received medical management after the index stroke.
Meaning In this study, 1 of 6 patients with a symptomatic CW had a recurrent stroke within 2 years, suggesting that medical management alone may not provide sufficient protection for patients with CW.
Importance A carotid web (CW) is a shelf-like lesion along the posterior wall of the internal carotid artery bulb and an underrecognized cause of young stroke. Several studies suggest that patients with symptomatic CW have a high risk of recurrent stroke, but high-quality data are lacking.
Objective To assess the 2-year risk of recurrent stroke in patients with a symptomatic CW.
Design, Setting, and Participants A comparative cohort study used data from the MR CLEAN trial (from 2010-2014) and MR CLEAN Registry (from 2014-2017). Data were analyzed in September 2020. The MR CLEAN trial and MR CLEAN Registry were nationwide prospective multicenter studies on endovascular treatment (EVT) of large vessel occlusion (LVO) stroke in the Netherlands. Baseline data were from 3439 consecutive adult patients with anterior circulation LVO stroke and available computed tomography (CT)–angiography of the carotid bulb. Two neuroradiologists reevaluated CT-angiography images for presence or absence of CW and identified 30 patients with CW ipsilateral to the index stroke. For these 30 eligible CW participants, detailed follow-up data regarding stroke recurrence within 2 years were acquired. These 30 patients with CW ipsilateral to the index stroke were compared with 168 patients without CW who participated in the MR CLEAN extended follow-up trial and who were randomized to the EVT arm.
Main Outcomes and Measures The primary outcome was recurrent stroke occurring within 2 years after the index stroke. Cox proportional hazards regression models were used to compare recurrent stroke rates within 2 years for patients with and without CW, adjusted for age and sex. The research question was formulated prior to data collection.
Results Of 3439 patients with baseline CT-angiography assessed, the median age was 72 years (interquartile range, 61-80 years) and 1813 (53%) were men. Patients with CW were younger (median age, 57 [interquartile range, 46-66] years vs 66 [interquartile range, 56-77] years; P = .02 and more often women (22 of 30 [73%] vs 67 of 168 [40%]; P = .001) than patients without CW. Twenty-eight of 30 patients (93%) received medical management after the index stroke (23 with antiplatelet therapy and 5 with anticoagulant therapy). During 2 years of follow-up, 5 of 30 patients (17%) with CW had a recurrent stroke compared with 5 of 168 patients (3%) without CW (adjusted hazard ratio, 4.9; 95% CI, 1.4-18.1).
Conclusions and Relevance In this study, 1 of 6 patients with a symptomatic CW had a recurrent stroke within 2 years, suggesting that medical management alone may not provide sufficient protection for patients with CW.
A carotid web (CW) is a shelf-like lesion located along the posterior wall of the internal carotid artery bulb. Imaging and pathologic analyses suggest CW is an intimal variant of fibromuscular dysplasia (FMD).1 Computed tomography angiography (CTA) imaging is a common noninvasive method for identification of CW.1-5 Because CWs protrude into the lumen of the carotid artery, flow disruption and blood stasis can occur, resulting in thrombus formation and subsequent ischemic stroke.2,6 Case-control studies have found that CWs are present in 9% to 37% of patients younger than 60 years with cryptogenic stroke, and that a CW increases the risk of ischemic stroke approximately 10- to 20-fold.3,7,8 Although data are limited, patients with CW with ischemic stroke are more often than usual women and of Black racial identity.2,4,7,9,10
It is unclear how patients with a symptomatic CW (those who have had an ipsilateral ischemic stroke) are best treated to prevent recurrent stroke.1 Most patients are treated with antiplatelet therapy, but some physicians advocate using anticoagulation therapy as a better choice because of focal blood stasis in the carotid artery caused by CW.1 Carotid artery stenting and surgical removal of the CW have also been reported, especially in those with recurrent ischemic stroke.9,10
One of the major knowledge gaps in deciding the optimal treatment is the lack of studies on the risk of recurrent stroke in patients with a symptomatic CW.1,3 A 2018 systematic review reported an ischemic stroke recurrence rate of 56% (with a median of 12 months to the recurrent stroke, range, 0-97 months) in patients with CW receiving medical management, but these data come from case reports and uncontrolled, retrospective, single center studies.10 Owing to publication and selection bias, the true recurrent stroke risk in patients with a symptomatic CW remains unknown. The aim of the current study was to assess the recurrent stroke risk in a population of patients with a large vessel occlusion (LVO) stroke of the anterior circulation and ipsilateral CW.
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