Carotid artery disease: Advancements in the treatment paradigm

Stroke remains a leading cause of death and long-term disability worldwide. Approximately 20% of these cases are caused by a narrowing of the carotid artery, the primary vessel supplying blood to the brain. For decades, the decision to treat this narrowing, either through open surgery (endarterectomy) or stenting, has relied almost exclusively on the severity of the narrowing and the presence of physical symptoms. However, these standards are based on studies conducted over thirty years ago. Since then, medical therapies and lifestyle management have improved significantly, leading to a substantial decline in stroke rates and calling the old treatment "paradigm" into question.

This thesis explores how to optimize stroke prevention in carotid disease by moving toward a more personalized treatment approach. Part I investigates new imaging biomarkers, demonstrating that patients with ocular (eye) symptoms may have a more vulnerable brain network than previously thought and that small, silent brain lesions appearing after surgery do not necessarily indicate a higher long-term stroke risk. Part II evaluates modern treatment strategies. A nationwide analysis showed that intensive blood-thinning therapy can be used safely during surgery without increasing bleeding risks. Most notably, results from the international ECST-2 trial revealed that patients with a low-to-intermediate predicted risk of stroke may benefit more from optimized medical therapy alone rather than undergoing an invasive procedure. By integrating clinical risk factors with advanced imaging, this research provides a roadmap for reducing unnecessary surgeries while better protecting those at highest risk.