This paper shows that carotid-related stroke is not primarily a story of narrowing alone, but of vulnerable plaque biology, hidden high-risk lesions, and smarter individualized selection between medical therapy, surgery, and stenting. The full review is worth reading because it maps where modern carotid care is genuinely shifting, from stenosis percentage toward plaque-driven, multimodal stroke risk stratification.
Abstract: To synthesize multi-modal evidence regarding the pathophysiology, diagnostic biomarkers, and comparative outcomes of surgical and endovascular interventions for carotid-related stroke. The review utilises 1904 original studies with 8515101 total participants (topic deduplicated ΣN). The mapped evidence suggests that carotid-related stroke risk is driven less by luminal narrowing alone and more by plaque vulnerability, particularly intraplaque hemorrhage, inflammation, thrombus, and structural lesions such as carotid web; notably, intraplaque hemorrhage was associated with recurrent ischemic events even in mild-to-moderate stenosis (hazard ratio 2.12), and asymptomatic intraplaque hemorrhage was linked to incident stroke (hazard ratio 2.42). This same pattern is reflected in imaging studies where plaque-based models and morphology outperformed stenosis alone, with reported discrimination around area under the curve 0.74-0.90 in selected cohorts. Across treatment topics, carotid endarterectomy remained the benchmark for symptomatic high-grade stenosis, while transcarotid artery revascularization emerged as a promising alternative with low reported 30-day stroke or death rates around 0.8%-2.3% in prospective and registry studies; by contrast, contemporary medically treated asymptomatic stenosis cohorts often showed annual stroke risks below 1%. Clinically, the evidence map supports moving from a stenosis-only framework toward multimodal risk stratification that integrates plaque biology, symptom status, and procedural context when selecting medical therapy, surgery, or stenting. Future research should prioritize standardized prospective validation of plaque-based imaging and biomarker strategies, along with comparative trials in nonstenotic but high-risk carotid disease phenotypes.
Final search date and database lock: 2026-04-17 11:47:02 CEST
Plan: Pro (expanded craft tokens; source: PubMed)
Source: PubMed
Total Abstracts/Papers: 8303
Downloaded Abstracts/Papers: 3650
Included original and non-original Abstracts/Papers (all): 2182
Included original Abstracts/Papers (Vote counting by direction of effect): 1904
Reference Index (links used in paper): 252
Total participants (topic deduplicated ΣN): 8515101
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