J Stroke.  2021 May;23(2):253-262. 10.5853/jos.2020.05225.

Stroke Recurrence in First-Ever Symptomatic Carotid Web: A Cohort Study

Affiliations
  • 1Stroke Unit, Bordeaux University Hospital, Bordeaux, France
  • 2Neurology Department, Sud-Francilien Hospital, Corbeil-Essonnes, France
  • 3Neurology Department, Martinique University Hospital, Martinique
  • 4Neurology Department, Guadeloupe University Hospital, Guadeloupe
  • 5Vascular Surgery Department, Martinique University Hospital, Martinique

Abstract

Background and Purpose
Carotid web (CaW) is an intimal variant of fibromuscular dysplasia responsible for ipsilateral cerebral ischemic events (CIE). Symptomatic CaW likely has a high risk of recurrent CIE, but no salient prospective data are available. We aimed to assess recurrence rate and its predictors after a first-ever CIE.
Methods
Consecutive Afro-Caribbean patients who had cryptogenic first-ever CIEs (ischemic stroke [IS] or transient ischemic attack [TIA]) associated with ipsilateral CaW were included in this multicenter observational cohort study. The follow-up (January 2008 to March 2019) focused on CIE recurrences. Kaplan-Meier method assessed rates of recurrences and Cox proportional hazards regression analyzed risk factors.
Results
Ninety-two patients (79 first-ever ISs and 13 TIAs; mean age±standard deviation, 49.8±9.9 years; 52 [56.5%] women) were included. During a mean follow-up of 50.5±29.6 months, 19 (20.7%) patients experienced recurrent ipsilateral CIEs (16 ISs and three TIAs). Of 23 patients receiving surgery/stenting treatment, no recurrence occurred after the intervention (median follow-up, 39.8 months [interquartile range, 27.6 to 72.4]). Under medical treatment alone, the annual recurrent CIE rate was 6.9%, and the cumulative rate was 4.4% at 30-day, 10.8% at 1-year, 19.8% at 2-year, 23.2% at 3-year, and 27.3% at 5-year. Presence of silent cerebral infarctions was the only independent risk factor of CIE recurrences (hazard ratio, 6.99; 95% confidence interval, 2.4 to 20.4; P=0.004).
Conclusions
Under medical treatment alone, symptomatic CaW was associated with a high rate of recurrence that reached 27.3% at 5-year. Surgery/stenting seems to be efficient, and randomized control trials are required to confirm the benefit of these interventions.

Keyword

Ischemic stroke; Cohort studies; Carotid artery; Recurrence; Carribbean region; Fibromuscular dysplasia

Figure

  • Figure 1. Kaplan-Meier curves of cumulative rates of cerebral ischemic event and ischemic stroke recurrences in symptomatic carotid web patients medically treated. CIE, cerebral ischemic event; IS, ischemic stroke.

  • Figure 2. Illustrative case who experienced a recurrent ischemic stroke in the left MCA territory under antiplatelet treatment. Carotid web (CaW) (white arrow) on digital subtraction angiography obtained at the index event of transient right-side hemiplegia in a 42-year-old woman (A). The patient was treated with aspirin (160 mg/day). Eleven months later, the patient developed right hemiplegia and aphasia. Brain magnetic resonance imaging gradient echo sequences showed a low signal intensity lesion (white arrow) in the left middle cerebral artery (MCA) (B), and diffusion weighted imaging confirmed acute ischemic stroke in the left MCA territory (C). Sagittal (D) and axial (E) views of computed tomography angiography (CTA) showed a mural thrombus superimposed to the previously identified CaW (white arrows). Follow-up CTA obtained after anticoagulation for 2 weeks showed disappearance of the mural thrombus (white arrows): sagittal (F) and axial (G) plane.


Reference

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