Symptomatic carotid disease, characterized by atherosclerotic or non-atherosclerotic internal carotid artery disease with ipsilateral stroke symptoms, represents a critical condition in stroke neurology. This "hot carotid" state carries a high risk of stroke recurrence, with almost one-fourth of the patients experiencing recurrent ischemic events within 2 weeks of initial presentation. The global prevalence of significant carotid stenosis (conventionally defined as ≥50% narrowing) is estimated at around 1.8% in men and 1.2% in women and increases with age. Management of symptomatic carotid disease remains challenging, requiring a balance between urgent medical and surgical interventions and their associated risks. Current treatment approaches combine medical management, focusing on optimal antithrombotic therapy, with revascularization procedures such as carotid endarterectomy or carotid artery stenting. However, decision making has evolved beyond considering stenosis degree alone, now incorporating advanced imaging data on plaque composition and intraluminal characteristics. Even though there are numerous randomized trials, uncertainties persist regarding optimal management, particularly in light of improved medical therapies and emerging concepts like symptomatic non-stenotic carotid disease. Future research directions include exploring newer antithrombotic regimens, refining patient selection criteria for revascularization, and evaluating novel techniques like transcarotid artery revascularization.
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