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How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting
  1. Kosmas I Paraskevas1,
  2. Frank J Veith2,3,
  3. J David Spence4
  1. 1 Department of Vascular and Endovascular Surgery, Royal Free Hospital, London, UK
  2. 2 Department of Vascular Surgery, New York University Langone Medical Center, New York, USA
  3. 3 Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
  4. 4 Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Canada
  1. Correspondence to Professor J David Spence; dspence{at}


Offering routine carotid endarterectomy (CEA) or carotid artery stenting (CAS) to patients with asymptomatic carotid artery stenosis (ACS) is no longer considered as the optimal management of these patients. Equally suboptimal, however, is the policy of offering only best medical treatment (BMT) to all patients with ACS and not considering any of them for prophylactic CEA. In the last few years, there have been many studies aiming to identify reliable predictors of future cerebrovascular events that would allow the identification of patients with high-risk ACS and offer a prophylactic carotid intervention only to these patients to prevent them from becoming symptomatic. All patients with ACS should receive BMT. The present article will summarise the evidence suggesting ways to identify these high-risk asymptomatic individuals, namely: (1) microemboli detection on transcranial Doppler, (2) plaque echolucency on Duplex ultrasound, (3) progression in the severity of ACS, (4) silent embolic infarcts on brain CT/MRI, (5) reduced cerebrovascular reserve, (6) increased size of juxtaluminal hypoechoic area, (7) identification of intraplaque haemorrhage using MRI and (8) carotid ulceration. The evidence suggests that approximately 10%–15% of patents with asymptomatic stenosis might benefit from intervention; this will become more clear after publication of ongoing studies comparing stenting or endarterectomy with best medical therapy. In the meantime, no patient should be offered intervention unless there is evidence of high risk of ipsilateral stroke, from modalities such as those discussed here.

  • asymptomatic carotid stenosis
  • stroke risk
  • carotid endarterectomy
  • best medical therapy
  • identification of high risk subgroups

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors KIP wrote the first draft. FJV and JDS made revisions.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

  • Guest chief editor J David Spence

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