[Carotid artery stenosis: natural history and medical management]

Internal carotid artery stenosis (ICAS) is an important cause of ipsilateral stroke. The natural history of ICAS is related to the presence of ipsilateral symptoms, severity of stenosis, and stability of plaque in the lesion. With advances in diagnostic techniques and treatment strategies such as medication, conventional surgery, or endovascular surgery, patient outcomes have gradually improved following numerous randomized, controlled studies. Recently, the medication for asymptomatic ICAS has switched from antiplatelet therapy with aspirin alone to combination therapy with antiplatelet, antihypertensive, antilipidemic, and antidiabetic agents with smoking cessation, which is the current best medical management. This change has improved patient outcomes compared with medication alone in asymptomatic ICAS, and the outcomes are now similar to those after carotid endarterectomy (CEA) and carotid artery stenting (CAS) with 3-8-fold greater cost-effectiveness. These changes have been adopted in the treatment of symptomatic ICAS, and the best medical management is now a necessary strategy following surgical intervention such as CEA or CAS.