Endarterectomy for mild cervical carotid artery stenosis in patients with ischemic stroke events refractory to medical treatment.

A 62-year-old man and a 44-year-old man with unilateral cervical carotid artery stenosis (less than 50% with echolucent plaque and ulceration) suffered recurrent ischemic stroke events despite treatment with antiplatelet and anticoagulation drugs. Carotid endarterectomy (CEA) was performed under transcranial Doppler monitoring for the detection of micro-emboli using a microscope inserted through a skin incision to minimize pressure on the carotid arteries. The atheroma plaque included an ulcer with fresh thrombi in both patients. Both patients awoke from anesthesia without new neurological deficits, and no ischemic stroke events have recurred since CEA. Endarterectomy is an effective method for preventing stroke in patients with severe carotid stenosis (>70%), but the efficacy of this procedure for mild carotid stenosis (<50%) remains uncertain, regardless of carotid plaque characteristics. The present cases suggest that even mild stenosis of the cervical carotid artery may result in ischemic stroke events that are refractory to medical treatment if the stenosis is associated with echolucent plaque with ulceration. Endarterectomy is recommended to prevent further stroke in such patients.