Abstract
Current guidelines for primary and secondary prevention of stroke in patients with carotid atherosclerosis are based on the quantification of the degree of stenosis and symptom status. Recent publications have demonstrated that plaque morphology and composition, independent of the degree of stenosis, are important in the risk stratification of carotid atherosclerotic disease. This finding raises the question as to whether current guidelines are adequate or if they should be updated with new evidence, including imaging for plaque phenotyping, risk stratification, and clinical decision-making in addition to the degree of stenosis. To further this discussion, this roadmap consensus article defines the limits of luminal imaging and highlights the current evidence supporting the role of plaque imaging. Furthermore, we identify gaps in current knowledge and suggest steps to generate high-quality evidence, to add relevant information to guidelines currently based on the quantification of stenosis.
Highlights
The only variation compared with the 2011 guidelines was that carotid endarterectomy is indicated in the presence of $1 imaging characteristic that may be associated with high stroke risk in asymptomatic subjects
Regardless of whether population-based screening does or does not reach the point of being recommended, our roadmap will meet the needs of the patients with signs and symptoms regardless and, in so doing, increasingly provide screening options for patient subpopulations that would benefit. In this roadmap consensus article, we have defined the limits of luminal imaging and highlight current evidence supporting the role of plaque imaging in risk stratification and treatment of carotid artery atherosclerosis and stroke
These recommendations are supported by evidence that highlights the limits of risk stratification based on the degree of luminal stenosis alone and emphasize the predictive power of other features such as the presence of intraplaque hemorrhage (IPH)
Summary
The current guidelines for the management of both symptomatic and asymptomatic atherosclerosis are based on randomized trials comparing medical therapy with surgical interventions using the degree of stenosis together with symptom status without consideration of plaque morphology and composition.
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