The journey to improving stroke risk stratification for patients with carotid artery stenosis: from medical management to revascularization

Ischemic strokes remain a leading cause of mortality and morbidity worldwide. Carotid artery stenosis is a major risk factor for ischemic strokes. Although traditional carotid revascularization procedures are based on carotid stenosis, it has been increasingly recognized that plaque compositon plays an important role in plaque rupture and stroke occurence. Our narrative review aims to present the evidence related to 1) carotid atherosclerosis and plaque composition contributors to stroke, and 2) medical management and revascularization of patients with carotid artery stenosis for stroke prevention. For patients with severe carotid atherosclerosis, critical treatment modalities include best medical therapy and revascularization, specifically carotid endarterectomy (CEA) or carotid artery stenting (CAS) for symptomatic and asymptomatic individuals, according to stenosis guidelines (>50% and >70% stenosis, respectively). Landmark randomized controlled trials (RCTs) showcased the clinical value of surgery in reducing future stroke outcomes for both asymptomatic and symptomatic populations. Along with the latest advancements in medical therapy, results from modern RCTs are providing much needed evidence regarding the net benefits in revascularization for stroke risk reduction, namely in asymptomatic populations. Evidence suggests that carotid artery stenosis, the primary metric for CEA or CAS eligibility, is not always consistent with the degree of plaque instability. We emphasize the importance of combining plaque instability and carotid stenosis assessments to better classify at-risk patients. Along with integrations of interventions with modern medical treatment, novel findings from RCTs and consideration of stenosis and plaque instability will ultimately help improve individualized care leading to effective prevention of ischemic strokes.