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In this issue of Neurology®, Heck et al.1 discuss the need for evidence regarding intervention for asymptomatic carotid stenosis (ACS). They say it is not proven that the risk of stroke in asymptomatic carotid stenosis is well below that of intervention. They inveigh against the suggestion that a moratorium on intervention in low-risk ACS outside of randomized trials be accepted in order to foster the development of the evidence we need to settle how to manage ACS. They assert further that only randomized trials can provide valid evidence. However, results in carefully vetted randomized trials do not reflect real-world risks. Recent results in registries2 are much worse than in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST),3 which is being used widely to justify routine intervention in ACS (particularly in the United States). In this editorial, I review the reasons why a moratorium is needed.
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- © 2017 American Academy of Neurology
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