Trends and controversies in carotid artery stenosis treatment

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.

Keywords: carotid stenosis; endarterectomy; statins.

Figure 1.. Intraplaque hemorrhage.

( A) Time-of-flight magnetic resonance angiography shows roughly 70% stenosis due to a plaque with intraplaque hemorrhage (IPH). IPH is seen as an area of high signal intensity on the non-contrast T1-weighted double inversion recovery image, obtained at a resolution of 0.35 × 0.35 × 2 mm. ( B) A low-signal-intensity area of peripheral calcification is also present. Images courtesy of Bruce Wasserman, Johns Hopkins University.

Figure 2.. Features of complex plaque on magnetic resonance imaging.

( A) Two-dimensional (2D) time-of-flight magnetic resonance angiography image shows roughly 50% stenosis of the carotid bulb resulting from a complex plaque. ( B) Contrast-enhanced long-axis T1-weighted (T1W) 2D double inversion recovery (DIR) image, obtained at a resolution of 0.35 × 0.35 × 2 mm. (C) Axial contrast-enhanced fat-suppressed T1W DIR image obtained with a resolution of 0.35 × 0.35 × 2 mm through the plaque reveals an enhancing fibrous cap (FC), a low-intensity non-enhancing lipid-rich necrotic core (LRNC), and a dark area of calcification. Images courtesy of Bruce Wasserman, Johns Hopkins University.