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.
Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement / Paraskevas, K. I.; Mikhailidis, D. P.; Antignani, P. L.; Baradaran, H.; Bokkers, R. P. H.; Cambria, R. P.; Dardik, A.; Davies, A. H.; Eckstein, H. -H.; Faggioli, G.; e Fernandes, J. F.; Fraedrich, G.; Geroulakos, G.; Gloviczki, P.; Golledge, J.; Gupta, A.; Jezovnik, M. K.; Kakkos, S. K.; Katsiki, N.; Knoflach, M.; Kooi, M. E.; Lanza, G.; Liapis, C. D.; Loftus, I. M.; Mansilha, A.; Millon, A.; Nicolaides, A. N.; Pini, R.; Poredos, P.; Ricco, J. -B.; Riles, T. S.; Ringleb, P. A.; Rundek, T.; Saba, L.; Schlachetzki, F.; Silvestrini, M.; Spinelli, F.; Stilo, F.; Sultan, S.; Suri, J. S.; Zeebregts, C. J.; Chaturvedi, S.. - In: JOURNAL OF STROKE AND CEREBROVASCULAR DISEASES. - ISSN 1052-3057. - STAMPA. - 31:1(2022), p. 106182. [10.1016/j.jstrokecerebrovasdis.2021.106182]