Carotid artery disease: clinical features and management

The most common cause of ischaemic carotid territory stroke is thromboembolism from stenoses in the extracranial internal carotid artery (ICA). In the majority, embolism is preceded by an acute change in plaque morphology thereby predisposing the patient to overlying thrombus formation and embolization. The management of patients with carotid artery disease mandates risk factor modification, antiplatelet and statin therapy in everyone. There is grade A, level I evidence that recently symptomatic patients with 50–99% NASCET stenoses gain significant benefit from carotid endarterectomy (CEA), despite a small risk of perioperative stroke. The maximum benefit is conferred if the patient undergoes surgery as soon as possible after onset of symptoms. The management of patients with asymptomatic disease remains controversial. While the 2014 AHA Guidelines recommend that intervention is appropriate in ‘selected’ patients, there is a growing body of opinion that the majority should probably be treated conservatively, primarily because the risk of stroke on medical therapy is declining. The 2014 AHA Guidelines advise that carotid artery stenting (CAS) is an alternative to CEA in ‘average risk’ symptomatic and asymptomatic patients, though not without generating controversy (especially in asymptomatic patients). However, provided CAS can be performed rapidly in symptomatic patients with procedural risks similar to CEA, this alternative treatment strategy is justified. CAS should not, however, be delayed in order to get better results. In this situation, expedited CEA remains the treatment of choice.