Abstract

Internal carotid artery atherosclerosis is a major risk factor for stroke, accounting for 15–20% of ischaemic strokes. Revascularisation procedures—either carotid endarterectomy or carotid artery stenting—can reduce the risk of stroke for those with significant (>50%) luminal stenosis but particularly for those with more severe (70–99%) stenosis. However, advances in medical pharmacotherapy have implications for the relative benefit from surgery for symptomatic carotid atherosclerosis, as well as our approach to asymptomatic disease. This review considers the evidence underpinning the current medical and surgical management of symptomatic carotid atherosclerosis, the importance of factors beyond the degree of luminal stenosis, and developments in therapeutic strategies. We also discuss the importance of non-stenotic but high-risk carotid atherosclerotic plaques on the cause of stroke, and their implications for clinical practice.