Clinical Review: Best Medical Therapy Superior to Carotid Endarterectomy in Secondary Stroke Prevention in Symptomatic Extracranial Internal Carotid Artery Stenosis of 50-69%

Extracranial internal carotid artery stenosis poses a high risk of recurrent stroke or transient ischemic attack (TIA) after a TIA or minor stroke. Secondary prevention with carotid endarterectomy for high-grade stenosis between 70-99% has been well documented with large scale randomized controlled trials in both Europe and North America. The benefit of intermediate grade stenosis (50-69%) stenosis is not as clear and the present-day standard treatment guidelines do not favor surgery or best medical treatment. When the surgery trials were published in early 1990s, the medical therapy was not as clear or as aggressive. Over the past 20+ years, multimodality medical therapy has been strongly recommended in all stroke guidelines and significantly improved results of secondary prevention of 80-90% is achievable. This review will try to analyze the available data to provide the best treatment recommendation for patients with symptomatic extracranial internal carotid stenosis of 50-69%.