Objective:

To summarize key evidence regarding contemporary medical therapy, revascularization trials, and emerging approaches to risk assessment in asymptomatic carotid stenosis (aCAS) from 2021 to 2026.

Approach:

• Epidemiological Context: Discusses the increasing detection of aCAS due to aging populations and advanced imaging techniques.
• Historical Trials Review: Reviews landmark trials (ACAS, ACST-1) that established carotid endarterectomy as a treatment option and their limitations.
• Contemporary Medical Therapy: Explores advancements in medical therapy, including lipid-lowering strategies and improved control of vascular risk factors.
• Emerging Risk Assessment: Examines new methods for identifying vulnerable plaques and high-risk disease, including imaging and biomarker analysis.
• Redefining Asymptomatic: Considers the definition of 'asymptomatic' by including covert cognitive impairment.
• Individualized Management Framework: Proposes a precision-management framework based on multimodal biomarkers.

Key Findings:

• The prevalence of aCAS increases with age, particularly in individuals over 60.
• Contemporary best medical therapy has significantly reduced the incidence of ipsilateral ischemic stroke.
• Recent trials challenge the reliance on luminal stenosis as the primary criterion for intervention.

Interpretation:

The management of aCAS is shifting from a focus on anatomical assessment to a more nuanced approach that incorporates biological risk factors and advanced medical therapies.

Limitations:

• Historical trials were conducted before the advent of modern medical therapies, limiting their applicability to current treatment paradigms.
• The definition of 'asymptomatic' may need reevaluation to include cognitive impairments.

Conclusion:

The evolving landscape of aCAS treatment emphasizes the importance of individualized risk assessment and the integration of advanced medical therapies.