Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement.

Abstract

OBJECTIVES:

The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic.

MATERIALS AND METHODS:

A literature review was performed with a focus on data from recent studies.

RESULTS:

Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses.

CONCLUSIONS:

Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.

• Authors: Kosmas I Paraskevas, Dimitri P Mikhailidis, Pier Luigi Antignani, Hediyeh Baradaran, Reinoud P H Bokkers, Richard P Cambria, Alan Dardik, Alun H Davies, Hans-Henning Eckstein, Gianluca Faggioli, Jose Fernandes E Fernandes, Gustav Fraedrich, George Geroulakos, Peter Gloviczki, Jonathan Golledge, Ajay Gupta, Mateja K Jezovnik, Stavros K Kakkos, Niki Katsiki, Michael Knoflach, M Eline Kooi, Gaetano Lanza, Christos D Liapis, Ian M Loftus, Armando Mansilha, Antoine Millon, Andrew N Nicolaides, Rodolfo Pini, Pavel Poredos, Jean-Baptiste Ricco, Thomas S Riles, Peter Arthur Ringleb, Tatjana Rundek, Luca Saba, Felix Schlachetzki, Mauro Silvestrini, Francesco Spinelli, Francesco Stilo, Sherif Sultan, Jasjit S Suri, Clark J Zeebregts, Seemant Chaturvedi
• Journal: Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association (J Stroke Cerebrovasc Dis) Vol. 31 Issue 1 Pg. 106182 (Jan 2022) ISSN: 1532-8511 [Electronic] United States
• PMID: 34735900 (Publication Type: Journal Article, Review)
• Copyright: Copyright © 2021 Elsevier Inc. All rights reserved.

Topics

• Carotid Stenosis (therapy)
• Humans
• Practice Guidelines as Topic