Over the last few years, the advance in operator’s experience, the improvement in technology and the strong demand from patients for a less-invasive alternative to surgery has made carotid artery stenting (CAS) an equally efficient and safe procedure to carotid endarterectomy for the treatment of carotid artery stenosis [1–3]. The introduction of mechanical cerebral protection systems can be considered the cornerstone in the evolution of CAS; these devices aim to prevent emboli from reaching the brain, and their introduction in the majority of procedures is responsible for better outcomes reported in recent clinical trials and registries. Therefore, guidelines strongly recommend the use of embolic protection devices in all procedures [4]. Despite progress in CAS, periprocedural stroke rate remains significant, and has an important physical, mental and social impact on patients’ lives. Therefore, indication for treatment of asymptomatic patients is one of the most debatable issues in the literature. In particular, incidence of microembolization, during and after CAS, persists despite the use of cerebral protection devices. Diffusion-weighted MRI (DW-MRI) has been shown to be a sensitive tool in identifying new ischemic cerebral lesions that are caused by emboli during CAS. Cerebral ischemic lesions are observed by DW-MRI in 15–78% of patients after CAS, and most of them are not associated with acute neurological symptoms [5–7]. Clinical implication and impact on prognosis of asymptomatic cerebral microembolism is still debated. Recently, a large study analyzing the role of asymptomatic cerebral ischemic lesions after CAS on prognosis in terms of major adverse cardiac and cerebrovascular event (death, stroke and myocardial infarction) demonstrated that a positive DW-MRI after CAS was not an