Introduction: Selection of patients with asymptomatic carotid artery disease for carotid revascularization: The case for risk stratification

It is inarguable that primary prevention is the best option for reducing the burden of stroke in individual patients and society. Most strokes that occur in patients with asymptomatic carotid artery stenosis (CAS) are not preceded by warning transient ischemic attacks (TIAs),¹ and even when TIAs occur many patients don’t seek timely medical attention.² Therefore, the argument that carotid revascularization should be withheld in these patients waiting for a warning clinical sign is unacceptable because the first presenting symptom in the majority of patients will be a complete stroke. For each patient, clinicians should balance the net benefits of a given preventive therapy (medical, endovascular, or surgical), against its associated risks and costs. Where possible, these assessments should be based on the results of randomized clinical trials.