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 patients with ipsilateral carotid web and ischemic stroke.

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 association between recurrent stroke in patients with ipsilateral carotid web receiving medical management (antiplatelet and anticoagulation) and carotid revascularization. A radial plot was used to visualize outliers. Random effects modeling was performed, and RR with 95% confidence intervals were reported.

We identified 14 observational studies that met the inclusion criteria.  These studies included a total of 513 patients: 241 in the medical treatment arm and 272 in the carotid revascularization arm. The mean age of these patients was 51 years (±4.5) and predominantly female (51%). In the meta-analysis, medical management, when compared to carotid intervention, is associated with higher risk of recurrent stroke (RR 1.23, 95% CI 1.08-1.40) p < 0.001, I² = 24.9%). In the intervention arm, 129 patients underwent carotid endarterectomy (CEA), and 143 patients underwent carotid artery stenting (CAS). When comparing CAS vs CEA, both were found to be equally effective for secondary stroke prevention (RR 1.01, 95% CI 0.136–1.59, p = 0.70, I²= 0%) with similar complication rate. 

These findings indicate that medical management is associated with increased recurrence suggesting that carotid revascularization should be considered. Large studies are needed to validate these findings.