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Review
. 2020 Oct;8(19):1279.
doi: 10.21037/atm-2020-cass-12.

The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence

José Fernandes E Fernandes  1   2   3 , Luis Mendes Pedro  3   4   5 , Isabel Gonçalves  6
Affiliations
Review

The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence

José Fernandes E Fernandes et al. Ann Transl Med. 2020 Oct.

Abstract

Management of asymptomatic carotid disease continues to challenge medical practice and present evidence is often conflicting. Stroke is a significant burden in Public Health and 11% to 15% appear as first neurologic event associated with asymptomatic carotid stenosis. Randomized trials provided support for Guidelines and Recommendations to intervene on asymptomatic stenosis, but at a known cost of a high number of unnecessary operations. Conflicting evidence from natural history studies and the widespread use of proper medical management including risk factors control, lowering-lipid drugs and strict control of arterial hypertension have reduced the incidence of strokes associated to asymptomatic carotid disease challenging established practice. Need to identify vulnerable lesions prone to develop thromboembolic brain events and also vulnerable patients at a higher risk of stroke is necessary and essential to further improve effectiveness of our interventions. After review of published literature on natural history of asymptomatic carotid stenosis, diagnostic methods to identify plaque vulnerability and present-day results of both endarterectomy and stenting, a strategy for management of asymptomatic carotid stenosis is suggested aiming to reduce unnecessary interventions and effectively contribute to stroke prevention.

Keywords: Asymptomatic; carotid; determinants; management; stenosis.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-2020-cass-12). The series “Carotid Artery Stenosis and Stroke: Prevention and Treatment Part I” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Macroscopic and histologic aspects of plaques with different phenotypes. On top a plaque with atherothrombosis and bottom a stable plaque.
Figure 2
Figure 2
Features of vulnerable and ruptured plaques.
Figure 3
Figure 3
Ruptured plaque, causing several minor strokes, despite determining only a moderate stenosis.
Figure 4
Figure 4
Plaque morphology studied by HD-ultrasonography. (A) Thick echogenic cap overlying an echolucent central core; (B) heterogenous plaque with juxtaluminal echolucent region; (C) erosion/ulcer in the surface of the plaque.
Figure 5
Figure 5
Flowchart for determination of the Activity Index. Adapted from (67).
Figure 6
Figure 6
Improved accuracy for the identification of ACS developing symptoms with AI and EAI in comparison % stenosis. Adapted from (78).
Figure 7
Figure 7
Modification of plaque structure with progression, erosion/mobile flap (see text).
See this image and copyright information in PMC

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