Carotid artery disease: clinical features and management

Stroke is the principal cause of persisting neurological disability in the Western world. The commonest cause of ischaemic carotid territory stroke is thromboembolism, usually from stenoses in the extracranial internal carotid artery. In the most patients embolism is preceded by an acute change in plaque morphology, thus predisposing the patient to overlying thrombus formation. The management of patients with symptomatic atherosclerotic carotid artery disease requires modification of risk factors, and antiplatelet and statin therapy in everyone. There is now grade A, level I evidence that selected patients (usually those with stenosis >70%) gain significant benefit from carotid endarterectomy, despite the small risk of perioperative stroke. Asymptomatic patients aged less than 75 years also gain significant benefit from carotid surgery, although the benefit is maximal in men. Carotid artery stenting has emerged as a less invasive alternative to surgery, avoiding both an incision and cranial nerve injury. Despite 12 randomized trials, however, there is still no consensus regarding its role in symptomatic patients. Two large randomized trials are due to report in 2009 and will greatly inform the debate. There is currently no role for stenting in asymptomatic patients at standard risk.