OBJECTIVE: Our group has previously demonstrated that patients with asymptomatic carotid artery stenosis (ACAS) demonstrate cognitive impairment. One proposed mechanism for cognitive impairment in patients with ACAS is cerebral hypoperfusion due to flow-restriction. We tested whether the combination of a high-grade carotid stenosis and inadequate cross-collateralization in the Circle of Willis (CoW) resulted in worsened cognitive impairment.
METHODS: Twenty-four patients with high-grade (≥70% diameter-reducing) ACAS underwent carotid duplex ultrasound, cognitive assessment, and 3D time-of-flight magnetic resonance angiography. The cognitive battery consisted of nine neuropsychological tests assessing four cognitive domains: learning and recall, attention and working memory, motor and processing speed, and executive function. Raw cognitive scores were converted into standardized T-scores. A structured interpretation of the magnetic resonance angiography images was performed with each segment of the CoW categorized as being either normal or abnormal. Abnormal segments of the CoW were defined as segments characterized as narrowed or occluded due to congenital aplasia or hypoplasia, or acquired atherosclerotic stenosis or occlusion. Linear regression was used to estimate the association between the number of abnormal segments in the CoW, and individual cognitive domain scores. Significance was set to P < .05.
RESULTS: The mean age of the patients was 66.1 ± 9.6 years, and 79.2% (n = 19) were male. A significant negative association was found between the number of abnormal segments in the CoW and cognitive scores in the learning and recall (β = -6.5; P = .01), and attention and working memory (β = -7.0; P = .02) domains. There was a trend suggesting a negative association in the motor and processing speed (β = -2.4; P = .35) and executive function (β = -4.5; P = .06) domains that did not reach significance.
CONCLUSIONS: In patients with high-grade ACAS, the concomitant presence of increasing occlusive disease in the CoW correlates with worse cognitive function. This association was significant in the learning and recall and attention and working memory domains. Although motor and processing speed and executive function also declined numerically with increasing abnormal segments in the CoW, the relationship was not significant. Since flow restriction at a carotid stenosis compounded by inadequate collateral compensation across a diseased CoW worsens cerebral perfusion, our findings support the hypothesis that cerebral hypoperfusion underlies the observed cognitive impairment in patients with ACAS.

暂无摘要。

OBJECTIVE: To determine the optimal treatment strategy for patients with asymptomatic carotid stenosis.
METHODS: The authors reviewed clinical guidelines for the management of patients with asymptomatic carotid stenosis 60-99%, as well as medical studies and meta-analyses comparing carotid endarterectomy and optimal drug therapy in asymptomatic patients between 1993 and 2023.
RESULTS: The choice of treatment strategy for patients with asymptomatic carotid artery stenosis is still a controversial issue. There were several large randomized clinical trials comparing carotid endarterectomy with optimal medical therapy in asymptomatic patients at the end of the 20th century. However, drug therapy has undergone significant changes calling into question the relevance of previous results. This review highlights the evolution of management of patients with asymptomatic carotid stenosis and also presents modern approaches to the treatment of these patients.
CONCLUSIONS: Patients younger 75 years old gain an advantage from carotid endarterectomy with small perioperative risk compared to optimal drug therapy and yearly risk of cerebral embolism. Patients with asymptomatic carotid stenosis 80-99% are candidates for carotid endarterectomy due to higher risk of acute cerebrovascular accident at least until more data are available. The choice of the best tactics for a particular patient should be made individually depending on own experience and patient\'s adherence to therapy and lifestyle correction. The results of the ACTRIS (2025) and CREST-2 (2026) studies are expected to clarify this issue.
UNASSIGNED: Определить оптимальную тактику лечения больных с асимптомным каротидным стенозом на современном этапе развития медикаментозной терапии и хирургической техники.
UNASSIGNED: Авторами проведен обзор клинических рекомендаций разных стран мира по ведению пациентов с асимптомным каротидным стенозом 60—99%, а также медицинских исследований и метаанализов, сравнивающих каротидную эндартерэктомию и применение оптимальной медикаментозной терапии у асимптомных больных за период с 1993 по 2023 г.
UNASSIGNED: Выбор тактики лечения пациентов с асимптомным стенозом сонных артерий в последнее время остается дискуссионным вопросом. В конце XX века было проведено несколько крупных рандомизированных клинических исследований, сравнивающих каротидную эндартерэктомию с оптимальной медицинской терапией у асимптомных больных. Однако на сегодняшний день медикаментозная терапия претерпела значительные изменения, что ставит под сомнение актуальность результатов этих исследований. В данном аналитическом обзоре в хронологическом порядке освещены этапы развития взглядов медицинского сообщества на тактику ведения пациентов с асимптомным каротидным стенозом, а также представлены современные подходы к лечению этой группы больных.
UNASSIGNED: У пациентов младше 75 лет лучше пойти на небольшой периоперационный риск и удалить источник микроэмболии навсегда, чем вести на оптимальную медикаментозную терапию и иметь ежегодный риск эмболии сосудов головного мозга; пациентов с 80—99% асимптомным каротидным стенозом также следует рассматривать как кандидатов на каротидную эндартерэктомию в связи с повышенным риском острого нарушения мозгового кровообращения по крайней мере до момента получения новых данных. Выбор лучшей тактики для конкретного пациента должен быть сделан индивидуально с учетом опыта лечебного учреждения, а также приверженности больного к медикаментозному лечению и коррекции образа жизни. Результаты исследований ACTRIS (2025) и CREST-2 (2026) ожидаемо внесут ясность в решение данного вопроса.

暂无摘要。

OBJECTIVE: Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear.
METHODS: Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response.
RESULTS: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered \"recently symptomatic\" should be reduced from the current definition of \"6 months\" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence.
CONCLUSIONS: The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.

OBJECTIVE: The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS.
METHODS: A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: \"asymptomatic carotid stenosis,\" \"carotid endarterectomy\" (CEA), \"carotid artery stenting\" (CAS), and \"transcarotid artery revascularization\" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS.
RESULTS: BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking.
CONCLUSIONS: The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction.

BACKGROUND: Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its\' management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5 years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis.
METHODS: Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined.
RESULTS: We noted a statistically significant (P < .001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90 day mortality and combined neurological event and 90 day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P < .001), combined perioperative neurological ischemic event and 90 day mortality (aOR 2.13, 1.62-2.80, P < .001), long term mortality (HR 1.62, 1.12-2.29, P < .001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P = .007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA.
CONCLUSIONS: Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy.

BACKGROUND: Recommendations for surgical versus conservative treatment of asymptomatic carotid stenosis (ACS) are based on prospective randomized trials, some of which were performed several decades ago. However, during this time, \"best medical treatment\" (BMT) for conservative therapy of arteriosclerotic patients has evolved significantly. Because of the associated risk reduction of ACS, surgical therapy is increasingly being questioned. By identifying clinical and morphological risk parameters, subgroups could be identified that might, however, benefit from invasive therapy. Consequently, multidisciplinary therapy decision-making requires an increasingly patient-individualized approach.
UNASSIGNED: Revaskularisierung der asymptomatischen Carotisstenose – sinnvoll oder obsolet?
UNASSIGNED: Die Empfehlungen zur operativen im Vergleich zur konservativen Therapie der asymptomatischen Carotisstenose (ACS) basieren auf prospektiv randomisierten Studien, die teilweise vor mehreren Jahrzehnten durchgeführt wurden. Seitdem hat sich das «best medical treatment» (BMT) für die konservative Therapie arteriosklerotischer Patientinnen und Patienten jedoch relevant weiterentwickelt. Aufgrund der damit verbundenen Risikoreduktion für neurologische Komplikationen bei Vorliegen einer ACS wird die operative Therapie zunehmend in Frage gestellt. Durch die Identifikation von klinischen und bildmorphologischen Risikoparametern konnten Subgruppen identifiziert werden, die jedoch weiterhin von einer invasiven Therapie vermehrt profitieren könnten. Die multidisziplinäre Therapieentscheidung bedarf folglich einer zunehmend patientenindividualisierten Herangehensweise. Schlüsselwörter: Asymptomatische Carotisstenose, Carotis-Endarterektomie, Carotis-Stenting, bestmögliche medizinische Therapie.
UNASSIGNED: Revascularisation de la sténose carotidienne asymptomatique – utile ou obsolète?
BACKGROUND: Les recommandations concernant le traitement chirurgical par rapport au traitement conservateur de la sténose carotidienne asymptomatique (SCA) resposent sur des essais prospectifs randomisés, dont certains ont été réalisés il y a plusieurs décennies. Cependant, pendant ce temps, le «Best medical treatment» (BMT) pour le traitement conservateur des patients artériosclérotiques a considérablement évolué. En raison de la réduction du risque de SCA qui y est associé, la thérapie chirurgicale est de plus en plus remise en question. En identifiant les paramètres de risque cliniques et morphologiques, il est possible d‘identifier des sous-groupes qui pourraient toutefois bénéficier d‘une thérapie invasive. Par conséquent, la prise de décision thérapeutique multidisciplinaire nécessite une approche de plus en plus individualisée pour chaque patient. Mots-clés: Sténose carotidienne asymptomatique, endartériectomie carotidienne, stenting carotidien, meilleur traitement médicalpossible.

OBJECTIVE: Substantial controversy exists regarding asymptomatic carotid stenosis (ACS) and its potential role in the pathophysiology of cognitive impairment. If proven, this hypothesis may suggest an additional definition for symptomatic carotid disease that would alter current management. This study aimed to synthesize the literature evaluating the relationship between impaired cerebral hemodynamics and cognition in patients with ACS.
METHODS: A literature search was performed using MEDLINE, Embase, and EBM Reviews through May 2022. We included prospective case-control studies that used validated, objective measure(s) of either global cognition or one or more domains of cognitive function and assessed cerebrovascular reserve (CVR).
RESULTS: Five studies were included, comprising a total of 782 patients with moderate (50%-69%) to severe (70%-99%) ACS. Patients with ACS and impaired ipsilateral CVR demonstrated significant cognitive impairment compared with controls. Patients with unilateral or bilateral ACS and normal CVR had cognitive scores similar to controls. Those with bilateral CVR impairment demonstrated the lowest cognitive scores.
CONCLUSIONS: This review lends support to the claim that cognitive impairment, likely the result of impaired cerebral hemodynamics, is an under-recognized morbidity in patients with ACS. CVR may serve as an additional tool to determine whether patients are in fact symptomatic from their carotid stenosis and warrant consideration for intervention.

Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.