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Medical management and revascularization for asymptomatic carotid stenosis: a meta-analysis of randomized controlled

Yu Gao1,2,3, Lijun Wang1,3, Hongjian Zhang1,4

  • 1Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China.

Journal of Neurology
|March 20, 2026
PubMed

Insights

Contemporary medical management for asymptomatic carotid stenosis shows comparable stroke and mortality risks to revascularization procedures like carotid endarterectomy (CEA) or stenting (CAS). These findings support current guidelines prioritizing optimized medical therapy.

Area of Science:

  • Vascular Surgery
  • Neurology
  • Cardiology

Background:

  • Historical trials supported revascularization for asymptomatic carotid stenosis.
  • Contemporary medical management (statins, antithrombotics, BP control) may reduce stroke risk.
  • This meta-analysis compares current medical management versus revascularization (CEA/CAS).

Purpose of the Study:

  • To compare the efficacy of contemporary medical management against revascularization (CEA/CAS) for asymptomatic carotid stenosis.
  • To evaluate stroke and mortality risks in patients undergoing different treatment strategies.
  • To inform clinical practice and guideline recommendations.

Main Methods:

  • Searched PubMed, Embase, Cochrane Library, and Web of Science databases until December 5, 2025.
  • Included three RCTs (SPACE-2, ECST-2, CREST-2) involving 3,426 patients.
  • Primary outcome: composite of stroke/death; secondary outcome: ipsilateral ischemic stroke.

Main Results:

  • No significant difference in the primary outcome (stroke/death) between revascularization and medical management (4.76% vs. 6.40%).
  • All-cause mortality did not differ significantly between groups (7.7% vs. 9.50%).
  • Subgroup analyses showed no added benefit of CEA or CAS over medical management alone.

Conclusions:

  • Contemporary medical management offers comparable stroke and mortality risks to revascularization for asymptomatic carotid stenosis.
  • Findings support current guidelines emphasizing optimized medical therapy and stringent patient selection for revascularization.
  • This meta-analysis validates the effectiveness of modern medical interventions in managing this condition.
Abstract

Keywords:
Asymptomatic carotid stenosisCarotid endarterectomyCarotid stentingMedical managementRe-vascularization

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