For patients unable to take anticoagulants for whatever reason, aspirin remains the only proven therapy, but trials are in progress. There has been increasing interest in the role of surgery following stroke, with little support for interventions other than carotid endarterectomy. Ideally the intervention should take place in specialist centers. Further, randomized clinical trials are required for other interventions such as carotid angioplasty with or without stenting. The recent completion of the European and North American trials has given clear outcomes.
Risk is highest early after transient ischemic attack or minor stroke.
North American surgeons are more likely to intervene in asymptomatic carotid artery disease. If a transient ischemic attack or stroke occurs, either should be investigated and managed in a specialist center offering organized stroke care. There is increasing evidence that early intervention, the time window being as little as three hours, may reduce long-term disability and death. Very few places are at present able to meet this time frame. Patients need immediate access to appropriate investigations, including computed tomography or magnetic resonance imaging, and access to specialists who understand the management of multiple risk factors and the likely outcome of intervention.