Moving beyond luminal stenosis: imaging strategies for stroke prevention in asymptomatic carotid stenosis

With progressive improvements in medical therapy and resultant reductions in stroke risk, luminal stenosis criteria are no longer adequate to inform decisions to pursue surgical revascularization in patients with asymptomatic carotid artery stenosis.

In this evidence-based review, we discuss the imaging-based risk stratification strategies that take into account factors beyond luminal stenosis measurements, including cerebral hemodynamics and plaque composition. The existing literature lends support to the use of certain imaging tests in patients with asymptomatic carotid stenosis including cerebrovascular reserve testing, MRI of plaque composition, ultrasound of plaque echolucency, and transcranial Doppler evaluation for microemboli. The highest quality evidence thus far in the literature includes only systematic reviews and meta-analyses of cohort studies with no randomized trials having yet been performed to show how these newer imaging biomarkers could be used to inform treatment decisions in asymptomatic carotid stenosis. Beyond the need for randomized trials, there are additional important steps needed to improve the relevance of evidence supporting risk assessment strategies. Imaging studies evaluating the risk of stroke in carotid disease should clearly define asymptomatic versus symptomatic disease, use uniform definitions of clearly defined outcome measures such as ipsilateral stroke, ensure that imaging interpretations are performed in a manner blinded to treatments and other risk factors, and include cohorts which are on modern intensive medical therapy. Such studies of risk stratification for asymptomatic carotid stenosis will be most valuable if they can integrate multiple high-risk features (including clinical risk factors) into a multi-factorial risk assessment strategy in a manner that is relatively simple to implement and generalizable across a wide range of practice settings. Key Messages: Together, modern imaging strategies allow for a more mechanistic assessment of stroke risk in carotid disease compared to luminal stenosis measurements alone, which, with further validation in randomized controlled trials, may improve current efforts at stroke prevention in asymptomatic carotid stenosis.