LAUSR

A Systematic Literature Review of Patients with Carotid Web and Acute Ischemic Stroke Zhang AJ, Dhruv P, Choi P, Bakker C, Koffel J, Anderson D, et al. Stroke 2018;49:2872-6. Study design: A search was conducted of MEDLINE through PubMed (1946-December 15, 2017), Embase through Ovid (1947-week 50, 2017), and the Cochrane Library through Wiley (ending December 15, 2017). Key findings: Of 160 patients with carotid webs, 135 (84%) were symptomatic and 24 (15%) were asymptomatic (1 could not be classified). Twenty-six patients (22%) had bilateral carotid webs. Regarding symptomatic patients, the median age was 46 years, 70% were black, 67% were women, and the majority (84%) had <50% internal carotid artery stenosis. Forty-seven (28%) symptomatic patients were managed medically (91% with antiplatelet agents); more than half of these patients (56%) suffered recurrent strokes distal to the carotid web during follow-up (median, 12 months; range, 0-97 months). Treatment of the other 70 (72%) symptomatic patients was equally divided between carotid endarterectomy and carotid stenting (CAS), and there were no complications. Conclusion: Carotid webs lead to ischemic stroke in younger patients with a high stroke recurrence rate in medically managed symptomatic patients, whereas carotid endarterectomy and CAS effectively prevented recurrent stroke. Commentary: A carotid web is also known as atypical focal carotid bulb fibromuscular dysplasia (FMD). It is defined as an intraluminal filling defect of the posterolateral wall of the most proximal part of the internal carotid artery. This atypical pathologic process is different from the classic “string of beads” seen in medial FMD. The underlying mechanism of stroke in carotid web patients is thought to be due to turbulent flow and stasis just distal to the web, resulting in thrombus and embolus. This study reported that more than half of patients with symptomatic carotid webs who were treated medically (primarily antiplatelet agents) had recurrent strokes. I find three aspects of this report intriguing (or defying belief, in other words). First, the large majority of symptomatic carotid web patients had only mild stenosis, which does not make a lot of sense. Why should lesser degrees of stenosis be associated with more thrombus beyond the web? Second, why did these patients undergo CAS and not plain old carotid balloon angioplasty, which is the recommended treatment for most patients with classic symptomatic FMD despite antiplatelet administration? Third, the authors recommend that patients with carotid web who had a stroke should be treated with CAS because antiplatelet agents did not prevent future strokes in half the patients. However, currently, antiplatelet agents are recommended as first-line treatment of patients with symptomatic carotid FMD, not carotid balloon angioplasty or CAS. Again, it does not make sense why a single web should be treated more aggressively than multiple “webs” or defects found in classic carotid FMD.