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Abstract and Introduction
Abstract
Incidental findings pose considerable management dilemmas for the treating physician and psychological burden for the respective patient. With an aging population, more patients will be diagnosed with asymptomatic internal carotid artery stenosis. Patients will have to be counseled with regard to treatment options according to their individual risk profile and according to professionals' knowledge of evidence-based data derived from large randomized control trials. Treatment consensus has long been lacking for patients with asymptomatic carotid artery stenosis prior to any randomized controlled trials. Additionally, an individual's risk profile may be hard to assess according to knowledge gained from randomized controlled trials. Moreover, while earlier studies compared carotid endarterectomy and medical therapy, in the past years, a new therapeutic modality, carotid artery angioplasty and stenting, has emerged as a possible alternative. This has been evaluated in a recent randomized controlled trial, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which compared carotid endarterectomy with angioplasty and stenting in both symptomatic and asymptomatic patients. The following review summarizes current knowledge of the natural history, diagnosis, and treatment strategies to counsel patients with asymptomatic carotid artery stenosis.
Introduction
Since the advent of modern neuroradiological imaging, incidental findings have become common, with clinically significant findings present in about 2%–8% of patients undergoing MR imaging of the brain. The management of these incidental findings poses considerable treatment dilemmas and psychological burden for the patient because there is no widespread agreement of treatment concepts. Treatment dilemmas have traditionally been particularly pronounced in patients with incidental or asymptomatic cerebrovascular pathological entities. This dilemma partly stems from the fact that, while most cerebrovascular pathological entities may cause catastrophic events, their proposed surgical treatment is not without important risks. The risk of treatment may further be accentuated in the mind of the patients because they are asymptomatic when the lesion is incidentally found and any intervention carries only a hypothetical benefit in the future.
Careful consideration of the natural history and possible benefit of various management options is particularly necessary in cases of asymptomatic carotid artery stenosis, for which treatment consensus has been lacking, prior to any randomized controlled trials. Given that roughly 2 million Americans may be harboring an asymptomatic carotid artery stenosis, the optimum treatment is of considerable public health interest. In the following review, we discuss the prevalence, natural history, progression rate, diagnostic modalities, and the results of randomized controlled trials highlighting our current understanding of the management of asymptomatic internal carotid artery stenosis.
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