title: Identifying high-risk asymptomatic carotid stenosis.
abstract: BACKGROUND
  With more intensive medical therapy, the risk of stroke in patients with asymptomatic carotid stenosis (ACS) is now below the risk of carotid endarterectomy or stenting (intervention); ∼ 90% of patients would be better with only medical therapy. It is important, therefore, to have methods to identify the ∼ 10% of patients who stand to benefit from intervention.
  
  
  METHODS
  We review the evidence that the risk of asymptomatic stenosis is now below the risk of intervention, and evidence for several approaches to identifying high-risk ACS: transcranial Doppler embolus detection, echolucency and neovascularity on ultrasound, ulceration on three-dimensional ultrasound, plaque composition on magnetic resonance imaging (MRI), plaque inflammation on positron emission tomography and assessment of cerebral blood flow reserve.
  
  
  CONCLUSIONS
  Carotid endarterectomy or stenting should be performed only in patients with ACS if they have microemboli on transcranial Doppler, three or more ulcers detected on three-dimensional ultrasound or other features of unstable plaque such as plaque echolucency on ultrasound, intraplaque hemorrhage detected on MRI, inflamed plaques detected on PET/CT or reduced cerebral blood flow reserve. Most patients with ACS (∼ 90%) would be better off with intensive medical therapy than with intervention.
authors.affiliation: University of Western Ontario, Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute , London , Canada.
authors.forename: Chrysi
authors.initials: C
authors.lastname: Bogiatzi
authors.forename: Myra S
authors.initials: MS
authors.lastname: Cocker
authors.forename: Robert
authors.initials: R
authors.lastname: Beanlands
authors.forename: J David
authors.initials: JD
authors.lastname: Spence