Open research questions in Cerebrovascular and Carotid Artery Diseases

What the literature leaves open

• The need to account for changes in CAS technique when interpreting randomized evidence. The lack of a comprehensive comparison of CAS and CEA across different procedural eras. The uncertainty surrounding the comparative 30-day safety of CAS and CEA.

  Carotid Artery Stenting vs Endarterectomy Across Procedural Eras · 2026 · DOI

• Single-arm retrospective study, - Small sample size of 28 patients, - Limited generalizability to other populations

  Direct balloon dilatation angioplasty for intracranial atherosclerotic stenosis-related acute ischemic stroke: a single-arm retrospective study of technical feasibility and safety · 2026 · DOI

• Further studies are needed to compare DBDA to other treatment options for ICAS-LVO, - Larger sample sizes are needed to confirm the safety and efficacy of DBDA, - Studies should investigate the long-term outcomes of DBDA for ICAS-LVO

  Direct balloon dilatation angioplasty for intracranial atherosclerotic stenosis-related acute ischemic stroke: a single-arm retrospective study of technical feasibility and safety · 2026 · DOI

• BackgroundCalcification in carotid plaques has been suggested to represent a stabilizing plaque feature, but previous findings are conflicting.

  Sex-Specific Associations of Carotid Plaque Calcification Subtypes with Stroke, TIA, and Retinal Ischemia · 2026 · DOI

• Whether histologically defined calcification subtypes are associated with distinct cerebrovascular event phenotypes and whether these associations differ by sex remain unclear.

  Sex-Specific Associations of Carotid Plaque Calcification Subtypes with Stroke, TIA, and Retinal Ischemia · 2026 · DOI

• Altered NVC may contribute to cognitive impairment in vascular pathology, but evidence is limited by inconsistent definitions and by the conflation of paired neuronal–haemodynamic NVC measures with haemodynamic-only, model-derived, or imaging-derived proxy measures.

  Paired neuronal-haemodynamic neurovascular coupling measures and cognitive performance in vascular pathology: protocol for a systematic review and meta-analysis · 2026 · DOI

• BACKGROUND AND OBJECTIVES: Nonstenotic (<50%) carotid plaques (NSCPs) are increasingly recognized as potential embolic sources in embolic stroke of undetermined source (ESUS), but their etiologic role remains uncertain because of limited data and the lack of standardized definition of high-risk plaque.

  CTA-Based Plaque-RADS to Assess Etiologic Role of Nonstenotic Carotid Plaques in Patients With Embolic Stroke of Undetermined Source · 2026 · DOI

• Abstract Rescue stenting (RS) is increasingly used for intracranial artery stenosis-related large vessel occlusion (ICAS-LVO), but optimal patient selection remains uncertain.

  Effect Modification of Rescue Stenting in ICAS-Related Middle Cerebral Artery Occlusion: The Role of Thrombectomy Failure, Stenosis Severity, and ASPECTS · 2026 · DOI

• However, there are limited studies on combining clinical indicators such as the TyG index with carotid ultrasound parameters to assess the risk of IS.

  Application of TyG index and carotid ultrasound parameters in the prediction of ischemic stroke · 2025 · DOI

• BACKGROUND AND OBJECTIVES: The management of anterior circulation tandem lesion stroke remains controversial, given its under-representation in randomized thrombectomy trials and uncertainty regarding optimal extracranial carotid intervention.

  Emergent Carotid Stenting for Acute Anterior Circulation Ischemic Stroke With Tandem Lesions · 2025 · DOI

• BACKGROUND AND OBJECTIVES: Management of carotid lesions during endovascular therapy (EVT) in patients with acute ischemic stroke (AIS) due to tandem lesions (TL) remains controversial, and long-term prognosis data are scarce.

  Emergent Carotid Artery Stenting in Patients With Acute Ischemic Stroke With Tandem Lesions · 2025 · DOI

• However, the underlying causal pathophysiologic mechanism of this relationship compared with a non-CAS strategy remains unclear.

  Mediation Analysis of Acute Carotid Stenting in Tandem Lesions · 2024 · DOI

• However, it remains unclear whether these benefits observed in animal studies also work in humans.

  Dietary Choline Intake Is Beneficial for Cognitive Function and Delays Cognitive Decline: A 22-Year Large-Scale Prospective Cohort Study from China Health and Nutrition Survey · 2024 · DOI

• The study suggests that future breakthroughs will rely heavily on multidisciplinary convergence. The study highlights the importance of artificial intelligence and radiomics in present-day research. The study suggests that the development of physics-informed carotid digital twins is a future direction for precise, patient-specific stroke risk management.

  Bibliometric Analysis and Visualization of Vulnerable Carotid Plaque Research (2010-2025): From Morphological Imaging to Artificial Intelligence and Digital Twins · 2026 · DOI

• The study identifies a gap in the current state of research on vulnerable carotid plaque. The study notes that plaque rupture is a biophysical event that is still subjective to measure.

  Bibliometric Analysis and Visualization of Vulnerable Carotid Plaque Research (2010-2025): From Morphological Imaging to Artificial Intelligence and Digital Twins · 2026 · DOI

• The detection of coronary inflammation is challenging. There is a need for a position-sensitive positron-counting catheter to record quantitative location-specific uptake of targeted radiotracers against inflammation.

  Intravascular position-sensitive positron-counting catheter for atherosclerotic plaques · 2026 · DOI

• Spectral Doppler systems differ from conventional duplex ultrasound in that they use simple transducer pairs without beamforming. The lack of imaging makes it impossible to determine the angle of insonation, preventing accurate velocity measurements. Structural measurements like IMT and plaque size are unavailable.

  Deep learning for carotid Doppler spectra classification · 2026 · DOI

• Further evaluation of the approach in larger, more diverse populations. Investigation of the potential application in non-specialist settings. Development of more advanced explainable AI tools for Doppler signal analysis.

  Deep learning for carotid Doppler spectra classification · 2026 · DOI

• The complexity and variability of carotid plaque ultrasound images. The need for accurate and reliable plaque assessment and risk prediction. The limitations of conventional machine learning models in plaque assessment.

  A clinically deployable deep learning model for automated stroke risk stratification in carotid atherosclerotic plaque · 2026 · DOI

• The accuracy and reproducibility of assessing plaque vulnerability-related features remain constrained by physicians’ subjective interpretation. There is a need for a clinically deployable deep learning model for automated stroke risk stratification.

  A clinically deployable deep learning model for automated stroke risk stratification in carotid atherosclerotic plaque · 2026 · DOI

• Detecting subtle plaque changes during early treatment phases. Individual responses to statin therapy vary considerably. Limited clinical application of MRI due to high costs and practical implementation barriers.

  Deep learning-based early prediction of carotid plaque response to lipid-lowering therapy using longitudinal multimodal ultrasound imaging · 2026 · DOI

• The inability to detect subtle plaque changes during early treatment phases. The lack of a validated model for carotid plaque treatment response prediction using longitudinal multimodal ultrasound imaging.

  Deep learning-based early prediction of carotid plaque response to lipid-lowering therapy using longitudinal multimodal ultrasound imaging · 2026 · DOI

• The prognostic implications of different degrees of stenosis severity are not well characterized. There is a need for studies that investigate the association between stenosis severity and recurrent stroke risk.

  Association between intracranial arterial stenosis severity and recurrent stroke risk in elderly ischemic stroke patients · 2026 · DOI

• Whether increasing ICAS severity confers incremental recurrence risk in medically treated elderly patients in routine clinical practice remains incompletely characterized.

  Association between intracranial arterial stenosis severity and recurrent stroke risk in elderly ischemic stroke patients · 2026 · DOI

• Traditional carotid artery research faces several challenges due to the limitations of its research methods. The field is shifting from exploratory computational applications toward clinically oriented and translational research. The study highlights the need for a guiding framework for future research in the field.

  Artificial intelligence in carotid research: a 25-year bibliometric analysis of global trends and future directions · 2026 · DOI

Most-cited papers in Cerebrovascular and Carotid Artery Diseases

• Beneficial Effect of Carotid Endarterectomy in Symptomatic Patients with High-Grade Carotid Stenosis · New England Journal of Medicine · 1991 · 7,041 citations
• Endarterectomy for Asymptomatic Carotid Artery Stenosis · JAMA · 1995 · 5,346 citations
• Benefit of Carotid Endarterectomy in Patients with Symptomatic Moderate or Severe Stenosis · New England Journal of Medicine · 1998 · 2,899 citations
• MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis · The Lancet · 1991 · 2,777 citations
• Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST) · The Lancet · 1998 · 2,745 citations
• Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis · New England Journal of Medicine · 2010 · 2,573 citations
• Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients · New England Journal of Medicine · 2004 · 2,440 citations
• Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial · The Lancet · 2004 · 2,035 citations
• Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis · The Lancet · 2003 · 1,348 citations
• Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery · The Lancet · 2004 · 1,216 citations

Most recent work

• Distinct Perforator Hemodynamic Phenotypes Differentiate Mechanisms of Single Subcortical Infarction: In Vivo Evidence from 7T Phase-Contrast MRI · International Journal of Stroke · 2026
• Predictive Value of Baseline High-Resolution MRI Features for In-Stent Restenosis in Symptomatic Nonacute Intracranial Atherosclerotic Occlusion · CardioVascular and Interventional Radiology · 2026
• ‘It works in practice, but does it work in theory?’ An important addition to the body of real-world evidence supporting carotid endarterectomy · Vascular Medicine · 2026
• Neurocognitive Changes and Cerebral Blood Flow in Patients with Symptomatic Carotid Artery Stenosis before and after Carotid Endarterectomy · Journal of Korean Neurosurgical Society · 2026
• Medical Management for Patients With Asymptomatic Carotid Disease · Neurology · 2026
• Long-term outcomes after endovascular stent-graft repair of traumatic extracranial carotid artery injuries: a single Level I centre retrospective cohort · Injury · 2026
• CTA-Based Plaque-RADS to Assess Etiologic Role of Nonstenotic Carotid Plaques in Patients With Embolic Stroke of Undetermined Source · Neurology · 2026
• Bibliometric Analysis and Visualization of Vulnerable Carotid Plaque Research (2010-2025): From Morphological Imaging to Artificial Intelligence and Digital Twins · Research in Health Science · 2026
• Intravascular position-sensitive positron-counting catheter for atherosclerotic plaques · EJNMMI Physics · 2026
• Plaque-level machine-learning prediction of carotid plaque vulnerability on computed tomography angiography · Neuroradiology · 2026

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