Disease of cervical arteries: contemporary imaging, medical management and endovascular treatment

Cervical artery diseases, encompassing both atherosclerotic and non-atherosclerotic disorders of the carotid and vertebral arteries, remain a major cause of ischemic stroke and transient ischemic attack (TIA) worldwide. Although luminal stenosis has traditionally guided diagnostic and therapeutic decision-making, recent advances have shifted the focus toward comprehensive vascular assessment, incorporating plaque vulnerability, vessel wall pathology, inflammatory activity, and individualized cerebrovascular risk stratification. Simultaneously, substantial progress in multimodal vascular imaging, intensive medical therapy, carotid revascularization techniques, and endovascular interventions has transformed the contemporary management of cervical artery disease. This review provides a comprehensive and clinically oriented overview of the diagnosis and management of extracranial carotid and vertebral artery diseases, including both atherosclerotic and non-atherosclerotic etiologies such as cervical artery dissection, fibromuscular dysplasia, and large-vessel vasculitides. Current evidence regarding clinical presentation, screening strategies, physical examination, multimodal imaging, optimal medical therapy, carotid endarterectomy, carotid artery stenting, and endovascular treatment is critically reviewed in light of the most recent international guidelines and landmark clinical trials. Particular emphasis is placed on emerging concepts including vulnerable plaque imaging, high-resolution vessel wall magnetic resonance imaging, advanced computed tomography techniques, and evolving imaging biomarkers that facilitate personalized risk assessment and treatment selection. Future perspectives regarding artificial intelligence, radiomics, quantitative plaque characterization, and precision cerebrovascular medicine are also discussed. By integrating current evidence with practical clinical decision-making, this review aims to provide clinicians with an updated framework for the diagnosis, risk stratification, and evidence-based management of cervical artery diseases while highlighting evolving directions that are expected to shape future stroke prevention strategies.