How should a patient with symptomatic grade 5 carotid atherosclerotic stenosis (≈70‑90% occlusion) following an acute stroke be managed?

Management of Grade 5 Carotid Atheroma After Stroke

For a patient with symptomatic 70-90% carotid stenosis following acute stroke, carotid endarterectomy (CEA) should be performed within 14 days of symptom onset, provided the perioperative stroke/death risk is <6% and the patient does not have contraindications such as severe disability, large infarct territory, or hemorrhagic transformation. 1

Immediate Medical Management (Start Today)

Dual antiplatelet therapy is the cornerstone of initial treatment:

• Aspirin 81-325 mg PLUS clopidogrel 75 mg daily for 21 days if revascularization cannot be performed immediately 1, 2, 3
• This reduces early recurrent stroke risk while awaiting intervention 1

High-intensity statin therapy should be initiated immediately regardless of baseline cholesterol levels to stabilize the plaque 1, 2

Blood pressure control targeting <140/90 mmHg is recommended 1, 2

Common pitfall: Do not delay antiplatelet therapy while awaiting imaging or vascular consultation—this increases stroke risk 2, 4

Urgent Revascularization Assessment

Timing is critical: CEA should ideally be performed within 2 weeks (14 days) of the index stroke event to achieve maximal benefit 1, 3, 4

The 18-month ipsilateral stroke risk with medical therapy alone for 80-89% stenosis is approximately 28%, which CEA reduces to 6-9% 3

Contraindications to Early Revascularization (First 48 Hours)

Do not proceed with revascularization if any of the following are present 1:

• Acute carotid occlusion
• Major persistent neurological deficit (Modified Rankin Scale ≥3)
• Middle cerebral artery infarction involving >1/3 of territory
• Parenchymal hemorrhage on imaging
• Impaired consciousness

CEA vs. Carotid Artery Stenting (CAS)

CEA is the preferred procedure for symptomatic 70-90% stenosis in patients with 1, 3:

• Age <75 years with average surgical risk
• Favorable neck anatomy
• No severe comorbidities

CAS may be considered as an alternative in 1:

• High surgical risk patients (severe heart/lung disease)
• Age >80 years
• Prior neck surgery or radiation
• High or low carotid bifurcation anatomy
• Carotid restenosis after previous CEA

Important caveat: Both procedures show similar long-term stroke prevention, but CAS has higher perioperative minor stroke risk while CEA has higher myocardial infarction and cranial nerve palsy risk 5

Perioperative Antiplatelet Management

For CEA 2, 4:

• Continue aspirin 81-325 mg daily perioperatively
• Do not stop antiplatelet therapy—this reduces perioperative stroke risk

For CAS 1, 3:

• Dual antiplatelet therapy (aspirin + clopidogrel) for at least 1 month after stenting
• Then transition to lifelong single antiplatelet therapy

Post-Revascularization Management

Antiplatelet therapy 1, 2:

• After the initial 21-30 day period, transition to lifelong single antiplatelet therapy (aspirin 75-325 mg daily OR clopidogrel 75 mg daily)
• Do not continue dual antiplatelet therapy long-term—this increases bleeding risk without additional benefit 2, 4

Surveillance imaging 2, 3:

• Duplex ultrasound within the first month after procedure
• Repeat at 6 months
• Annual surveillance thereafter

Common pitfall: Oral anticoagulants should not be used instead of antiplatelet therapy unless there is a specific indication like atrial fibrillation 1, 2, 4

Quality Control Requirements

Revascularization should only be performed at centers where 1, 3:

• Perioperative stroke/death rate is documented at <6% for symptomatic patients
• Outcomes are routinely audited
• A multidisciplinary vascular team is available

The benefit of revascularization disappears if complication rates exceed these thresholds 3

Special Consideration: Tandem Lesions

If the patient has both extracranial carotid stenosis and intracranial large vessel occlusion 1:

• Emergency endovascular treatment with mechanical thrombectomy is indicated
• Carotid stenting or balloon angioplasty can be performed simultaneously
• No consensus exists on the order of intervention (carotid first vs. intracranial first)—this is driven by case-specific anatomy

Risk Factor Modification (Ongoing)

Beyond the acute phase, address 1, 2:

• Smoking cessation
• Diabetes management (HbA1c <7%)
• Plant-based diet
• Regular physical activity
• Screen for concomitant coronary and peripheral arterial disease (present in 50-75% of carotid stenosis patients) 6

Critical understanding: Atherosclerotic plaque does not regress with medical therapy—the goal is stabilization and prevention of progression 3