Carotid Revascularization Versus Medical Management for Ischemic Stroke with Ipsilateral Carotid Web: A Systematic Review and Meta-Analysis.

OBJECTIVES

Carotid artery web is an underrecognized cause of ischemic stroke and is associated with a high risk of recurrent events. It is uncertain whether medical management or carotid revascularization is beneficial for patients with ischemic stroke and ipsilateral carotid web. In the absence of large randomized clinical trials and observational studies, we performed a systematic review and meta-analysis comparing medical management and carotid revascularization in this population.

METHODS

The systematic review was registered in PROSPERO (CRD42024485069). We searched five databases: Embase, Scopus, MEDLINE, Web of Science, and CINAHL. We included observational studies that studied the association between recurrent stroke in patients with ipsilateral carotid web receiving medical management (antiplatelet and anticoagulation) and carotid revascularization. Random effects modeling was performed, and risk ratio with 95% confidence intervals were reported.

RESULTS

We included 17 studies (16 published and 1 institutional study). In the medical management group, 32% (90/281) of patients experienced recurrent ischemic stroke ipsilateral to the carotid web. The meta-analysis revealed a significantly lower risk of recurrent ischemic stroke with carotid revascularization (relative risk 0.11, 95% confidence interval 0.06-0.28, p < 0.001, I = 14.5%). Both carotid endarterectomy and carotid artery stenting were equally effective in reducing recurrent stroke risk (relative risk 0.44, 95% confidence interval 0.11-1.76, p = 0.99).

INTERPRETATION

Carotid revascularization is associated with reduced recurrence rates, with no difference between revascularization subtypes (carotid endarterectomy vs carotid artery stenting). However, given the small, heterogeneous cohorts and the uncertain natural history of carotid artery web under medical management, these findings should be interpreted with caution until prospective, controlled comparative effectiveness studies are performed. ANN NEUROL 2025;98:625-633.