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

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 KnoflachM. 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

Research output: Contribution to journalReview articlepeer-review


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.

Original languageEnglish (US)
Article number106182
JournalJournal of Stroke and Cerebrovascular Diseases
Issue number1
StatePublished - Jan 2022
Externally publishedYes


  • Asymptomatic carotid stenosis
  • Best medical treatment
  • Carotid endarterectomy
  • Carotid plaque
  • Stroke

ASJC Scopus subject areas

  • Surgery
  • Rehabilitation
  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine


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