To determine the optimal management of symptomatic carotid web (CaW) based on stroke recurrence rate and the Modified Rankin Scale (mRS) as a measure of patient functional outcome.

Carotid web is a form of fibromuscular dysplasia which can cause impaired blood flow, stasis, thrombus formation, and embolic stroke. Treatment of CaW includes medical or surgical management, which includes carotid stenting (CAS) or carotid endarterectomy (CEA) to prevent recurrent ipsilateral ischemic stroke. Our objective was to conduct a systematic review to determine the optimal management of symptomatic CaW.

Cochrane, PubMed, Embase, and Web of Science were searched. Inclusion criteria were symptomatic ischemic stroke or TIA ipsilateral to CaW, documented medical management and/or interventional management for secondary prevention, follow-up period at least one week, age≥ 18 years, sample size of three or more patients, and CaW diagnosed on CT-angiography or conventional angiography. Data from studies comparing medicine (anticoagulant or antiplatelet) and intervention (stent or CEA) are summarized.

429 studies were identified; 8 studies were selected, including 355 patients. The average age ranged from 44.6-55.0 years. Median follow-up ranged from 3-38 months. Four studies compared cohorts of surgical or medical treatment. 7.1% of patients receiving medical therapy alone and 20.4% of surgical therapy alone experienced recurrent stroke. Four studies reported stroke within the same patient population who received medical then surgical management. Patients who received medical treatment first had a 50% stroke recurrence, after which 2.3% of patients treated surgically experienced a stroke. Two studies reported post-intervention mRS; one reporting mean mRS of 2±0.7 among surgical and 2±2 among medical management, while the other reported 0±0 for CEA, 1±0 for stent and 1±0 for medical management.

Overall, revascularization of a symptomatic CaW showed lower rates of stroke recurrence compared to best medical management.  The small sample size, however, limits analysis of the mRS.