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Clinical Trial
. 2021 Jul 1;78(7):826-833.
doi: 10.1001/jamaneurol.2021.1101.

Assessment of Recurrent Stroke Risk in Patients With a Carotid Web

Valeria Guglielmi  1 , Kars C J Compagne  2   3 , Amir Hossein Sarrami  3 , Wouter M Sluis  4 , Lucie A van den Berg  1 , Pieter M van der Sluijs  3 , Daniel M Mandell  5 , Aad van der Lugt  3 , Yvo B W E M Roos  1 , Charles B L M Majoie  6 , Diederik W J Dippel  2 , Bart J Emmer  6 , Adriaan C G M van Es  7 , Jonathan M Coutinho  1 ; MR CLEAN trial and MR CLEAN Registry Investigators
Collaborators, Affiliations
Clinical Trial

Assessment of Recurrent Stroke Risk in Patients With a Carotid Web

Valeria Guglielmi et al. JAMA Neurol. .

Abstract

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr van den Berg reported grants from the Dutch organization for Health research and Health innovation (ZonMw) The MR CLEAN extension study was funded by the Dutch organization for Health research and Health innovation (ZonMw) and is registered under number 5073 in the Dutch trial register. during the conduct of the study. Dr van der Lugt reported grants from Angiocare BV paid to institution, grants from Covidien / EV3 paid to institution, grants from Medac GmbH / Lamepro paid to institution, grants from Stryker paid to institution, grants from Penumbra paid to institution, and grants from Dutch Heart Foundation paid to institution during the conduct of the study; grants from Stryker paid to institution, grants from Medtronic paid to institution, grants from penumbra paid to institution, grants from Cerenovus paid to institution, and grants from thrombolytic science Inc paid to institution outside the submitted work. Dr Roos reported other from Nico-Lab Moderate share holder outside the submitted work. Dr Majoie reported grants from TWIN Foundation paid to institution during the conduct of the study; grants from CVON/Dutch Heart Foundation paid to institution, grants from European Commission paid to institution, grants from Dutch Health Evaluation Program paid to institution, and grants from Stryker paid to institution outside the submitted work; and is shareholder of Nico-lab. Dr Dippel reported grants from Dutch Heart Foundation paid to institution, grants from Brain Foundation Netherlands paid to institution, grants from The Netherlands Organisation for Health Research and Development paid to institution, grants from Health Holland Top Sector Life Sciences & Health paid to institution, grants from AngioCare BV unrestricted grant paid to institution, grants from Covidien/EV3 unrestricted grant paid to institution, grants from MEDAC Gmbh/LAMEPRO unrestricted grant paid to institution, grants from Penumbra Inc unrestricted grant paid to institution, grants from Top Medical/Concentric unrestricted grant paid to institution, grants from Stryker unrestricted grant paid to institution, grants from Stryker European Operations BV unrestricted grant paid to institution, grants from Medtronic unrestricted grant paid to institution, grants from Thrombolytic Science, LLC unrestricted grant paid to institution, and grants from Cerenovus unrestricted grant paid to institution outside the submitted work. Dr Emmer reported Grants paid to institution by Leading The Change (ZonMW) and Health Holland (Dutch Ministry of Economic Affairs). Dr Coutinho reported grants from Boehringer Ingelheim (All fees paid to institute and used to fund research), grants from Bayer (All fees paid to institute and used to fund research), and grants from Medtronic (All fees paid to institute and used to fund research) outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow Diagram of Patient Selection
CTA indicates computed tomography angiography; EVT, endovascular treatment.
Figure 2.
Figure 2.. Kaplan-Meier Estimates of Recurrent Stroke and Recurrent Ipsilateral Ischemic Stroke During 2-Year Follow-up After the Index Stroke
A., During 2-year follow-up, 5 of 30 patients (17%) with a carotid web ipsilateral to the index stroke had a recurrent stroke compared with 5 of 168 patients (3%) without carotid web (hazard ratio, 5.0; 95% CI, 1.4-17.3; adjusted hazard ratio, 4.9; 95% CI, 1.4-18.1). B, During 2-year follow-up, 4 of 30 patients (13%) with a carotid web ipsilateral to the index stroke had a recurrent ischemic stroke ipsilateral to the index stroke compared with 2 of 168 patients (1%) without carotid web (hazard ratio, 9.9; 95% CI, 1.8-54.2; adjusted hazard ratio, 8.1; 95% CI, 1.4-46.8).
Figure 3.
Figure 3.. Carotid Webs on Computed Tomography Angiography Imaging at the Index Stroke in Patients With Recurrent Stroke During 2-Year Follow-up
Carotid webs are indicated by arrowheads. Detailed patient data are provided in Table 2.
See this image and copyright information in PMC

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