Abstract
Despite the completion of several multi-center trials, the management of carotid stenosis remains in flux. Key questions include the role of intensive medical management in the treatment of asymptomatic carotid stenosis. In addition, identification of patients with symptomatic stenosis who will most benefit from carotid revascularization remains a priority. The role of newer imaging techniques such as carotid plaque analysis with magnetic resonance imaging is also challenging current treatment paradigms. These topics are explored in this topical update.
Highlights
Extracranial internal carotid artery (ICA) stenosis is a leading cause of ischemic stroke, accounting for about 10% of strokes
The current European Society for Vascular Surgery guidelines take this into account, recommending consideration of carotid endarterectomy (CEA) for those with asymptomatic 60 to 99% stenosis with a life expectancy of more than 5 years and at least one feature suggestive of a higher stroke risk on best medical therapy[5]
In the Northern Manhattan Study, increased adherence to the Life’s simple 7 (LS7) metric was related to a graded reduction in stroke, and a risk reduction of 59% was reported in patients with the highest adherence[14]
Summary
Extracranial internal carotid artery (ICA) stenosis is a leading cause of ischemic stroke, accounting for about 10% of strokes. The current European Society for Vascular Surgery guidelines take this into account, recommending consideration of CEA for those with asymptomatic 60 to 99% stenosis with a life expectancy of more than 5 years and at least one feature suggestive of a higher stroke risk on best medical therapy[5]. It is crucial to stratify patients on the basis of life expectancy and characteristics of their carotid disease thought to increase stroke risk, such as plaque area, echolucency, presence of intraplaque hemorrhage (IPH) or silent infarction on magnetic resonance imaging (MRI), or evidence of spontaneous embolization on transcranial Doppler (TCD) Use of these additional imaging modalities should be considered in decision making for patients with ACS and is discussed later in this article. Such sequences may be acquired using 2D (double inversion recovery T1 and T2) or preferably with
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