Management of the near total internal carotid artery occlusion

Objectives. The risk of stroke in patients with near total internal carotid artery (ICA) occlusion is perceived to be high as stroke risk increases with severity of the stenosis. The management of this entity has not been addressed specifically in the existing randomised trials and thus it remains controversial. Methods. Systematic review of the relevant literature. Results. The management of patients with near total ICA occlusion remains controversial: some favour intervention whereas others have condemned it as dangerous or of no benefit. A prospective multicentre randomised trial regarding intervention versus best medical treatment for patients with symptomatic near total ICA occlusion seems difficult because of the large number of patients required to power the study. Nevertheless, it appears hard to decline surgery based on the current evidence. Conclusions. Because of the current controversy over the best management of the near total ICA occlusion, prospective observational studies are needed to demonstrate its prevalence in the symptomatic and asymptomatic population and any associated excess stroke risk. Based on the current evidence, surgery is the treatment of choice in most centres but its validity over best medical treatment remains untested.